Old Exam Questions Flashcards

Question

Femoral Hernia with discoloured bowel - you are accessing via a proximal thigh transverse incision. Can’t deliver up bowel. What is the BEST way to release the bowel? a. midline laparotomy and deliver b. Divide cooper c. Divide conjoint d. Divide transversalis and inguinal

Answer 1

B In general, umbilical hernia has a tendency to close on its own in approximately 80% of cases, and therefore elective repair should be deferred until approximately 5 years of age. Also, umbilical hernia is rarely associated with significant complications but there are unique exceptions to this general rule, for which an earlier elective repair should be considered. Although rare, a history of incarceration clearly warrants prompt surgical repair, irrespective of age. Enlarging umbilical hernia over time, in particular with a large skin proboscis more than 3 cm, or a significantly large umbilical fascial defect (>2 cm) is unlikely to resolve spontaneously; therefore, surgical repair should be considered at an early age.

Answer 2

A Selective contralateral exploration is offered after consultation with the parents of patients who fall into the following categories: girls younger than 5 years with a unilateral hernia, and premature infants. In boys with a question of bilateral disease, the authors recommend laparoscopy through the umbilicus to evaluate the contralateral side. Sabiston: Although early hernia repair may be associated with a higher risk for injury to the cord structures, recurrence rate, and postoperative apneic episodes, most pediatric surgeons advocate operative repair prior to discharge from the hospital for premature infants because of their significant risks for incarceration. However, for those infants diagnosed after hospital discharge, elective hernia repair may be deferred until the infant is beyond 52 weeks postconceptional age, when postoperative apnea risk decreases. In patients presenting with incarcerated inguinal hernia, unless there is clinical evidence of peritonitis, attempts are made to reduce the hernia. Manual reduction is successful in up to 70% of cases. Once reduced, the patient is admitted for observation and hernia repair is performed at 24 to 48 hours, when local tissue edema resolves. A nonreducible incarcerated hernia should be promptly explored in the operating room. Routine contralateral inguinal exploration at the time of symptomatic hernia repair for infants is standard practice based on the high incidence of contralateral patent process vaginalis (4% to 65%). However, the issue regarding the routine exploration of the asymptomatic contralateral side in toddlers remains unresolved. Most pediatric surgeons routinely explore the asymptomatic contralateral side in children 2 years of age or younger; some surgeons extend the contralateral exploration criteria to those up to 5 years of age.

Answer 3

Answer Key says D Multiple comorbidities that would improve with bariatric procedure; unacceptably high rate of recurrence with BMI 44.

Answer 4

Answer Key says A Sounds like a hydrocele? Ultrasound?

Answer 5

C 2012 ACC/AHA: dual antiplatelet for 12 months due to high rate of delayed stent thrombosis UTD: 12 months DAPT for DES, in patients at high risk for bleeding, can go to single after 6 months

Answer 6

C Management of the incision is a function of the condition of the fascia. When technical mistakes are made and the fascia is strong and intact,primary closure is warranted. If the fascia is infected or necrotic, débridement is performed. The incision can then be closed with retention sutures; however, to avoid tension, use of a prosthetic material may be preferred. Closure with an absorbable mesh (polyglactin or polyglycolic acid) may be preferable because the mesh is well tolerated in septic wounds and allows bridging the gap between the edges of the fascia without tension, prevents evisceration, and allows the underlying cause of the patient’s dehiscence to resolve.

Answer 7

Answer key says D. Maybe B? superiorly it is continuous with the inferior diaphragmatic fascia posteriorly it fuses with thoracolumbar fascia and is lost in the fat covering the posterior surface of the kidney inferiorly it is attached to the iliac crest and posterior margin of the inguinal ligament inferior to the inguinal ligament it is attached to the inguinal ligament by a fibrous tissue that forms the iliopubic tract medial to the femoral vessels it attaches to the pubis and pectineal line. It descends and forms the anterior part of the femoral sheath

Answer 8

A Dx is ? spigelian hernia or rectus sheath hematoma

Answer 9

A Boundaries of the inguinal canal (Fig. 9-17) are as follows: - Anterior: The anterior boundary is the aponeurosis of the external oblique muscle and, more laterally, the internal oblique muscle. Remember, there are no external oblique muscle fibers in the inguinal area, only aponeurotic fibers. - Posterior: In about ¾ of subjects, the posterior wall (floor) is formed laterally by the aponeurosis of the transversus abdominis muscle and the transversalis fascia; in the remainder, the posterior wall is transversalis fascia only. Medially the posterior wall is reinforced by the internal oblique aponeurosis. - Superior: The roof of the canal is formed by the arched fibers of the lower edge (roof) of the internal oblique muscle and by the transversus abdominis muscle and aponeurosis. - Inferior: The wall of the canal is formed by the inguinal ligament (Poupart’s) and the lacunar ligament (Gimbernat’s).

Answer 10

C A sliding inguinal hernia is a protrusion of a retroperitoneal organ through an abdominal wall defect. If all contents of the sac cannot be reduced, adhesions of viscera to the sac or a sliding component may be present.

Answer 11

C and D Most common hernia in females is indirect inguinal Metalgia paresthetica is syndrome of a dull ache, sharp pain, burning sensation, tingling or numbness in the distribution of the lateral cutaneous nerve of the thigh. Usually assoc with hernai repair

Answer 12

C D is also known as Howship Romberg sign

Answer 13

A ? Spigelian hernia vs rectus sheath hematoma

Answer 14

A | But technically it is along linea semilunaris, lateral to edge of rectus sheath, but not between the two

Answer 15

D Explore contralateral side in preemies and girls. In this case, family history is indication.

Answer 16

Answer key says C (aka hydrocelectomy) Best overall answer is hydrocoelectomy. Consider imaging to rule out varicocele from obstructed gonadal vein (retroperitoneal mass).

Answer 17

A Sabiston: most groin mesh infections can be salvaged with antibiotics; trial long-term abx before mesh removal.

Answer 18

B Hematoma/seroma: 4-6% Urinary retention: 2.1% Infection: 0.3-0.6%, recurrence 1-2% if Lichtenstein

Answer 19

A Debate about watchful waiting in men outside the 40-65 age range. The JAMA study (Watchful Waiting vs Repair of Inguinal Hernia in Minimally Symptomatic MenA Randomized Clinical Trial) included men age 18->65. 56% were 40-65, leading some to conclude that the results are only applicable to white men 40-65. However, 32% were >65, and the authors did not make any statements about age criteria, so I believe watchful waiting applies. At 11 years, crossover to repair was 62% for men <65 and 79% for men >66. Hernia-related adverse events were low, only 0.0018 per patient year. There was no difference in surgical complications between up-front surgery and delayed surgery. As Sabiston discusses, probably a greater risk in the elderly is decreased activity which is necessary for maintaining quality of life. If the hernia is impairing activity, it should probably be fixed as the risk of repair is low compared to risk of functional decline. Also, M&M is much higher in emergent repairs.

Answer 20

Answer key says B A is reasonable if comfortable with laparoscopic repair of colon injury An injury to the colon carries a much greater potential for a sinister outcome if the hernia repair is completed as planned. Therefore, the majority of surgeons will simply repair the injury and repair the hernia by a laparotomy. Some, however, have carried out the hernia repair with a simultaneous colon resection as a preplanned operation with an adequately prepared colon [18]. An unplanned event should terminate the laparoscopic repair. The further management of the injury and hernia repair should proceed similarly to that of the small bowel injury.

Answer 21

B Randomized trials and observational studies have provided adequate evidence that the laparoscopic approach to incisional hernia repair has a lower incidence of surgical site and mesh infection compared with open mesh repair. Laparoscopic repairs are also less painful, and patients recover more quickly. A systematic review involving 1003 patients from 11 trials found lower incidences of wound drainage (2.6 versus 67 percent) and wound infection (2.8 versus 16.2 percent) for laparoscopic incisional hernia repair compared with open hernia repair

Answer 22

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 23

C If it was upper do R thoractomy

Answer 24

A Gastrograffin followed by thin barium if no leak seen.

Answer 25

B Biopsy not required and contraindicated b/c makes adequate pathologic material to exclude malignancy is impossible to obtain and violation of the mucosal layer may complicate subsequent surgical resection. Diagnosis best on barium swallow. Esophageal endoscopic ultrasonography (EUS) may further help in the diagnosis, planning of surgery, and follow-up of these tumors. 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.

Answer 26

A Need to open to manage this complication. Thal brings up fundus as an onlay patch.

Answer 27

A If the initial repair was a tissue repair, either anterior or posterior approaches can be used for repair of the recurrent hernia. If the initial repair was a mesh repair, then the recurrent repair should preferably employ an approach in the space in which the tissues planes have not been violated previously. Selecting one approach over the other also depends on the experience and comfort of the surgeon with that technique. Although a laparoscopic approach might be preferable in previously repaired anterior tissue repair, the absence of a mesh with its associated scarring and fibrosis makes a redo anterior approach with mesh more feasible and acceptable, especially if laparoscopic expertise is not available.

Answer 28

B Only 2 prospective trials have been conducted on percutaneous cholecystostomy in high surgical risk acute calculous cholecystitis. Both showed no significant difference in mortality and possibly reduced costs and morbidity. However, percutaneous cholecystostomy can be performed safely on patients who are not otherwise operative candidates, such as ASA class IV and V and patients with severe sepsis. Percutaneous cholecystostomy may be the only treatment required for acalculous cholecystitis in the critically ill, with success rates between 57% and 100%.

Answer 29

``` C Only 2 prospective trials have been conducted on percutaneous cholecystostomy in high surgical risk acute calculous cholecystitis. Both showed no significant difference in mortality and possibly reduced costs and morbidity. However, percutaneous cholecystostomy can be performed safely on patients who are not otherwise operative candidates, such as ASA class IV and V and patients with severe sepsis. Percutaneous cholecystostomy may be the only treatment required for acalculous cholecystitis in the critically ill, with success rates between 57% and 100%. However, successful laparoscopic cholecystectomy is reported in surgical candidates. ```

Answer 30

D Gallbladder polyps that are 6–9 mm on ultrasound without signs of malignancy or risk factors for gallbladder cancer (e.g., age over 60, sessile morphology, gallstones, primary sclerosing cholangitis) can be safely observed with interval ultrasound studies.

Answer 31

B Biologic matrices provide a scaffold for tissue and vascular ingrowth. Today they are popular in abdominal wall reconstruction. Cross-linking is a chemical step that attempts to render the collagen of the biologic matrix less prone to degradation in vivo by naturally occurring collagenases. Cross-linking also delays cellular infiltration and neovascularization in the short term. A gradual remodeling of an implanted tissue graft is essential in abdominal wall repair, because too rapid of an absorption of the matric scaffold will result in graft failure and recurrence of the hernia. Because cross-linked matrixes are poorly incorporated by the host, they become encapsulated with fibrous tissue and act as foreign body material instead of serving as a scaffold for remodeling. Non-cross-linked matrices actually promote early vascularization and cellular ingrowth.

Answer 32

C Focal nodular hyperplasia (FNH) is the second most common benign hepatic lesion. FNH has no potential for malignancy, spontaneous rupture, or hemorrhage. The only indications for resection of FNH are symptoms (abdominal pain) and inability to rule out malignancy. A definitive diagnosis, however, is usually possible with modern imaging techniques. Asymptomatic FNH does not require intervention. Annual ultrasound for 2–3 years is prudent for women who wish to continue oral contraceptive (OCP) use.

Answer 33

D Hepatic adenomas (HA) are benign liver masses that tend to be hormonally sensitive. The classic presentation is in young women (aged 20s–40s) with a history of OCP use and in men with a history of anabolic steroid use. Many HAs regress with discontinuation of OCPs and steroids. Management strategies of HA are more aggressive than for other benign liver masses, because they have a risk of hemorrhage and malignant degeneration to hepatocellular carcinoma (HCC). The risk of hemorrhage or an occult focus of HCC increases in HAs greater than 5 cm in size. Indications for surgery include (1) size at least 5 cm, (2) male patient, and (3) inability to rule out malignancy. Management of an acute rupture with hemorrhage is initial angioembolization followed by elective resection. If possible, resection to negative margins should be done in case underlying HCC is identified on final pathologic analysis.

Answer 34

A Hepatic hemangiomas are the most common benign neoplasm of the liver. Hemangiomas have no risk of malignant degeneration and a very low risk of bleeding. Lesions smaller than 5 cm rarely cause symptoms. An asymptomatic hemangioma can be safely observed. Hemangiomas that bleed may be embolized. Indications for surgery are symptoms (recurrent abdominal pain) and extremely large lesions (>10 cm). For those requiring surgery, resection is the treatment of choice. Enucleation is possible in many cases, because the hemangioma tends to compress adjacent liver tissue, creating a plane of dissection.

Answer 35

B Gut = highly purified collagen processed from the submucosa layer of sheep intestine or the serosa layer of beef intestine. Absorbed based on whether it is plain or chromic, the tissue it is used in, and the general health status of the patient. Plain is absorbed by 70 days, with tensile strength maintained for 7–10 days. Plain gut treated with a chromium salt solution is called chromic gut. Prolongs absorption time to >90 days, with tensile strength retained for 10–14 days. Polyglactin 910 or Vicryl = synthetic absorbable suture formed from a copolymer of lactide and glycolide (from lactic and glycolic acid). The lactide slows water penetration into the suture, which improves the duration of tensile strength. Retain ~ 65% of original tensile strength 14 days after implantation. Absorption is minimal for ~ 40 days and complete by 56–70 days. Polyglecaprone 25 or Monocryl is virtually inert in time and absorbs predictably. At 7 days, 50–60% of initial strength remains, reduced to 20–30% at 14 days, with all original strength lost at 21 days. Absorption is complete at 91–119 days. Polydioxanone or PDS is a polyester that retains 70% of tensile strength at 14 days postimplantation, 50% at 28 days, and 25% at 42 days. Absorption is minimal until approximately the 90th day postoperatively and essentially complete within 6 months. Silk suture is braided raw silk. Surgical silk loses tensile strength when exposed to moisture. Although silk is classified as a nonabsorbable suture, long-term studies show that by 1 year, it has lost all of its tensile strength and usually cannot be detected in tissue after 2 years.

Answer 36

A Hyperplastic polyps do not portend any increased risk of developing colorectal malignancy and therefore require no increased surveillance from the standard 10-year follow-up.

Answer 37

A Patients with 1 or 2 adenomatous polyps, less than 10 mm in diameter, are considered low risk, and 10-year follow-up is recommended.

Answer 38

B Patients with 3 or more adenomatous polyps, 1 or more polyps greater than 10 mm in size, or adenomatous polyps with villous or high-grade histology are considered high risk, and 3-year follow-up is recommended.

Answer 39

D Incisional hernia is the most frequent complication after laparotomy, resulting in approximately 200,000 repairs annually. Both laparoscopic and open approaches are successfully used in the surgical treatment of incisional hernias. Multiple comparisons have been made, examining each technique’s advantages and disadvantages vis-à-vis the other. The laparoscopic approach has a lower rate of wound complications, mesh infection, and hospital length of stay compared with the open approach. This advantage is offset by higher major or severe complications, particularly intraoperative enterotomy, and hospital costs. Recurrence rates are similar for both approaches. The laparoscopic approach is especially recommended in obese patients or elderly patients with small to medium defects because of its minimal flap creation and soft tissue dissection.

Answer 40

B Recently, multiple RCTs were conducted comparing nonoperative management with antibiotics to surgery in patients with uncomplicated appendicitis. Nonoperative management, had a success rate of 44–85% in individual studies. Most recurrences in the nonoperative group occur within the first year after treatment. Surgery is associated with a higher rate of complications compared with nonoperative management. Mortality was similar between operative and nonoperative management. A meta-analysis of 4 randomized trials consisting of 900 patients found a relative risk reduction in complications of 31% in the antibiotic treatment group compared with the appendectomy group. Nonoperative management is associated with shorter length of stay and decreased sick leave time compared with surgical management. Antibiotic therapy may delay appendectomy in patients who are not improving, but this delay is not associated with an increased risk of developing complicated appendicitis, including perforation or peritonitis.

Answer 41

E In patients with cirrhosis, the diagnosis of HCC can be made with triple-phase CT scan. Liver Imaging Reporting and Data System (LiRADS) criteria include the presence of arterial-phase enhancement (hypervascularity), portal venous phase washout, and threshold growth if a historical comparison is available. The scale runs from 1 (definitely benign) to 5 (diagnostic of HCC). LiRADS 4 and 5 lesions can be treated without a biopsy. A tissue diagnosis may be necessary in low-risk patients and when there is nondiagnostic imagining. Serum alpha fetoprotein has a high positive predictive value when greater than 500 ng/mL but a low negative predictive value. Approximately 20% of patients with HCC have a normal alpha fetoprotein. Alpha fetoprotein levels are not used as a diagnostic criterion for HCC. An effective screening approach that significantly reduces HCC-related mortality has not been identified. Serial serum alpha fetoprotein screening in more than 5000 chronic hepatitis B carriers in China identified more early-stage cancers than the unscreened population but did not significantly reduce mortality. The authors concluded this was likely a function of a lead-time bias—diagnosing the disease earlier but not changing the disease-specific mortality. PET scans are neither sensitive nor specific for the diagnosis of HCC.

Answer 42

C Determinants of the malignant potential of a pancreatic cyst include mucin in the cyst contents, cyst size, solid tumor in the cyst, and main pancreatic duct dilation. Loculation within the cyst does not predict malignancy. Cysts containing serous fluid are generally benign and include serous cystadenomas and benign epithelial cysts. Accordingly, the patient with the largest mucin-containing cyst and greatest dilation of the main duct represents the patient with the highest risk of associated malignancy. Mucin-containing cysts include intraductal papillary neoplasms (IPMN) and mucinous cystic tumors (MCN). MCN occur almost exclusively in women 55–65 years old, whereas IPMN occur in older men and women, with men predominating. Current recommendation from guidelines recommend resection of all MCN, main duct IPMN, branch duct-IPMN with a solid component, main pancreatic duct size at least 1 cm, obstructive jaundice, or cytology suspicious or positive for cancer. Although guidelines recommend resection of the unilocular, mucin-containing cyst in the 55-year-old woman as it is a presumed MCN, the risk of malignant cells within the lesion is less than the 65-year-old man with the large IPMN with main duct involvement.

Answer 43

D Although only 30% of patients with HCC may qualify for operative treatment, surgery remains the best option available. Because the leading cause of death after resection for HCC is liver failure, proper preoperative assessment of hepatic reserve is essential to identify patients at risk. Both the Child-Pugh and Model for End-Stage Liver Disease classifications can aid in determining those patients at greatest risk. For example, Child-Pugh C patients have a greater than 25% perioperative mortality, and, consequently, resection is contraindicated. Triphasic liver CT can be used to calculate the future liver remnant. A future liver remnant less than 40% is predictive of postoperative liver failure. Finally, indocyanine green (ICG) clearance can be used to assess the functional capacity of the liver. The dye is injected into the bloodstream, and clearance from the liver is measured 15 minutes after injection. Less than 10% of the dye should be detectable at this point in normal functioning livers. With 15–20% retention, a 2-segment resection is possible. With 21–30% retention, a single segment or wedge resection is indicated. Greater than 40% retention of dye at 15 minutes is predictive of postoperative liver failure regardless of resection size. In this patient requiring a 2-segment resection for treatment of his 6-cm HCC, the minimum ICG clearance would be 80%, corresponding to a 20% retention rate, which would allow performance of a 2-segment resection without the development of liver failure.

Answer 44

D Palliative options for long-term chronic pancreatitis-induced pain include procedures involving pancreatic head resections, such as the Beger or Frey procedure or pancreaticoduodenectomy (Whipple procedure), surgical drainage procedures, or endoscopic ductal decompression. Options for surgical drainage can include procedures such as the Puestow procedure or modifications of this classic operation such as the Izbicki operation or Hamburg or Berne procedure. The Beger procedure includes duodenum-sparing resection of most of the pancreatic head with division of the pancreatic body over the portal vein and reconstruction via a side-to-side and side-to-end pancreaticojejunostomy to drain the remaining head and tail of the pancreas. The Frey procedure combines a duodenal-sparing pancreatic head resection with overlay pancreaticojejunostomy and longitudinal duct drainage without division of the pancreas. The Puestow procedure consists of opening the duct in a longitudinal fashion and draining it via a lateral pancreaticojejunostomy while preserving the head of the gland. Endoscopic treatment for pain related to chronic pancreatitis can be accomplished with sphincterotomy and stone extraction with or without ductal dilation or stent placement for main duct decompression. A randomized controlled trial demonstrated that surgical drainage of the pancreas required fewer reinterventions and was more effective in controlling pain and improving quality of life than endoscopic decompression. Approximately 20–25% of patients required reintervention after endoscopic decompression versus approximately 5% of surgically drained patients. There were no statistically significant differences in reintervention rates between patients undergoing Beger versus Frey procedures. Rates of exocrine insufficiency are typically more than 60% in patients undergoing either endoscopic decompression or surgery, and rates appear similar between Beger and Frey procedures. Rates of endocrine insufficiency appear to be lower than exocrine insufficiency and are similar between endoscopic and surgical drainage procedures. Endocrine insufficiency is lower with pancreatic head parenchymal-sparing surgical procedures than pancreaticoduodenectomy, but significant differences have not been seen between the different types of pancreatic parenchymal sparing operations. Randomized controlled trials show superior results from duodenal-preserving pancreatic head resections compared with pancreaticoduodenectomy. Mortality from chronic pancreatitis may result from surgical complications if operative drainage is performed; other causes include pancreatic cancer, gastrointestinal hemorrhage, or cardiovascular disease as a result of diabetes from endocrine insufficiency. In fact, cardiovascular disease secondary to endocrine insufficiency is the most common cause of death after Beger and Frey procedures.

Answer 45

D The use of nonabsorbable or slowly absorbable sutures has a lower hernia rate than quickly absorbable sutures. A continuous suture technique leads to a more rapid and stronger wound closure than interrupted sutures. Monofilament sutures result in fewer surgical site infections compared with braided sutures. A suture length-to-wound length ratio higher than 4-to-1 decreases the rate of incisional hernia by 4-fold. Finally, the use of 2-0 monofilament sutures mounted on a small needle (e.g., 20-mm tapered half-circle) with the placement of stitches within the aponeurosis 5–8 mm from the wound edge and 4–5 mm apart helps to minimize the rate of incisional hernia. Thus, for this patient, the use of a continuous, monofilament sutures with a 4:1 suture-to-wound length ratio is optimal.

Answer 46

A Necrotizing pancreatitis is seen in approximately 1 in 5 patients with pancreatitis and is associated with a mortality rate of 10–30%. Patients are at high risk for multiorgan failure and secondary infection of the necrotic pancreatic bed. The risk of secondary infection is 25–70%, adding to the already high rate of morbidity and mortality. After initial admission and resuscitation, patients with severe pancreatitis should undergo imaging to determine the extent of necrosis. Contrast-enhanced axial imaging is the modality of choice. The true extent of necrosis may not be apparent for several days. CT offers the additional benefit of assessing for further local complications associated with severe pancreatitis. Enteral nutrition should be started within 72 hours. The goal is to achieve an early positive nitrogen balance. If gastric feeds are not tolerated, continuous, jejunal feeds should be used. In the setting of a paralytic ileus, parenteral nutrition can be used until resolution of the ileus. Sterile necrosis must be distinguished from infected necrosis, because these 2 processes are managed differently. Antibiotics have no apparent role in the setting of sterile necrosis. Although some early studies supported the use of antimicrobial therapy in the setting of severe necrosis, 2 large, randomized, double-blinded, multicenter studies and a Cochrane meta-analysis determined prophylactic antibiotics were not protective. Infected necrosis warrants debridement. There is no indication for surgical debridement of sterile necrosis. Recently, several reports described the benefits of using a “step-up” approach to debridement. This approach advocates beginning with radiologic drainage, followed by minimally invasive retroperitoneal necrosectomy if drainage fails. This approach seeks to avoid the high morbidity and mortality associated with open necrosectomy.

Answer 47

C This patient presents with an impressive mass in the retroperitoneal space on the left. Twenty-four-hour urinary catecholamine collection is elevated. Therefore, unless proven otherwise, this patient has a pheochromocytoma. The enlarged mass and the appearance of other nodules in the periaortic area strongly suggest a malignant pheochromocytoma (figure 2). This tumor does not arise from the kidney, and attention should be turned to the appropriate preoperative workup and management of this patient in preparation for surgery. A pheochromocytoma is a tumor arising from the adrenomedullary chromaffin cells that commonly produce one or more catecholamines, including epinephrine, norepinephrine, and dopamine. In this case, urine catecholamines are strongly suggestive of pheochromocytoma, but this could be a false-positive. This patient has been on tricyclic antidepressants for 5 years. Therefore, checking peak values off the medication is clearly the best answer. Other medications that may cause falsely elevated tests for plasma and urine metanephrines include acetaminophen, labetalol, and cocaine. The literature states that 80–90% of patients with pheochromocytoma have sustained or paroxysmal hypertension. This is mostly due to increased peripheral resistance. The hypertensive pattern in patients with pheochromocytoma is very similar to those with primary hypertension with the exception of the tachycardia these patients can experience. Hypertension in pheochromocytoma is usually characterized by a high peripheral resistance and low cardiac index. Since 1990, 14 different susceptibility genes have been reported for patients with pheochromocytoma. Current guidelines recommend all patients with pheochromocytoma be engaged in “shared decision making for genetic testing.” This patient does not know his family history, and therefore, could possibly harbor a genetic predisposition. Identifying patients who may harbor the gene is of extreme importance for offspring. The p53 gene appears to have no role in predicting the behavior of pheochromocytoma.

Answer 48

A The relative risk of developing desmoid tumors is much higher in patients with familial adenomatous polyposis (FAP) compared with the general population. Desmoids occur in 7.5–16% of FAP patients. Gardner syndrome, considered a variant of FAP, includes extracolonic manifestations such as osteomas and desmoid tumors. Given her history of FAP and the location of the masses, a diagnosis of desmoid is most likely. Diagnosis of desmoids and other aggressive fibromatosis (AF) is made based on clinical, radiological, and histological parameters. AF/desmoids characteristically infiltrate deep tissue and muscles as opposed to pushing the adjacent tissue, as is seen in most sarcomas. MRI is an excellent tool for the identification and characterization of mesenteric masses (figure 1 and table 1). On MRI, the lesions are infiltrative with an irregular or lobulated contour. Homogeneous isointensity or mild hyperintensity on T1-weighted images and heterogeneous high signal on T2-weighted images is seen. For symptomatic patients, treatment should be based on the location of the tumor and potential morbidity of treatment. Treatment options include resection, radiation, or systemic therapy. Radiation can be preoperative, intraoperative, or postoperative. Systemic therapies for desmoids include anti-inflammatory drugs, hormonal (tamoxifen) agents, biologic agents (the tyrosine kinase inhibitor imatinib), or chemotherapy (doxorubicin). The decision making for treatment recommendations should be multidisciplinary and should include the preferences and quality-of-life considerations of the patient.

Answer 49

A Complex abdominal wall hernias represent a therapeutic dilemma for surgeons. They are fraught with a high recurrence rate, and the best technique for their repair is not yet established. Complex abdominal wall hernias are defined by clinical and patient factors. Clinical factors include open abdomen management, previously infected wound, previously repaired hernia, or hernias with loss of domain. Patient factors include obesity, active smoking, diabetes, or chronic obstructive pulmonary disease. These hernias have a much higher rate of recurrence than do noncomplex hernias and, thus, require a more extensive operation. Although the best operation for these hernias has yet to be determined, a retrorectus procedure is commonly used. In this repair, the mesh is placed between the rectus muscle and the posterior rectus sheath. The fascia is then closed above and below the mesh. This approach may require a release or separation of the muscular layers so the fascia can be closed without tension. The can be done using either an open or laparoscopic technique. Other principles guiding the use of mesh in the repair of hernias are as follows: The use of mesh seems to reduce recurrence rates and is recommended for the repair of complex hernias. The use of synthetic mesh is associated with an increased risk of infection. Mesh placed in the retrorectus position has lower complication rates, including recurrence, than does placement of mesh in the overlay or underlay positions. Every attempt should be made to close the abdominal wall native tissue regardless of the positioning of the mesh. Although the use of biologic mesh may reduce the infection rate, biologic meshes are thought to have a higher recurrence rate and are not considered superior in overall outcomes. Large-pore or lightweight mesh allows better tissue incorporation of the mesh, which is thought to help reduce the recurrence rate and possibly infection rate. Cross-linking is a feature of biologic mesh, and it is thought to prevent the degradation of the mesh, resulting in a lower incidence of recurrence.

Answer 50

C Urinary retention is reported to occur in up to 22% of patients after laparoscopic hernia repair. Risk factors include age greater than 60, a history of benign prostatic hypertrophy, and operating time greater than 2 hours. Urinary retention can still occur in young patients and seems to be more prevalent after laparoscopic repairs compared with open ones. When comparing laparoscopic repairs with open repairs, laparoscopic repairs tend to have longer operating times but similar recurrences and a faster return to work. Currently, there is no definitive evidence that one method (open, total extraperitoneal, or transabdominal) shows superiority over the others, so the approach can be determined by surgeon preference and patient choice, even in asymptomatic patients. Regarding asymptomatic patients, surgical repair is not mandatory, because only approximately 17% of patients will develop symptoms within 1 year from diagnosis, and this is typically not an incarcerated hernia. Chronic postoperative pain is a concern after inguinal repairs. Chronic pain can occur in up to 11% of patients, but only about 3–4% of patients have severe or activity-limiting symptoms. There is no definitive evidence that dividing the ilioinguinal nerve routinely during an open repair results in a reduction in the incidence of this chronic pain syndrome.

Answer 51

Idiopathic thrombocytopenic purpura (ITP) is a disease in which antibodies are formed against platelets, which results in consumption of the platelets and thrombocytopenia. These antibodies are created in the spleen, and a splenectomy is curative in approximately 75–85% of patients. ITP is associated with mucosal bleeding, petechiae, purpura, and ecchymoses. The diagnosis is made by the presence of antiplatelet antibodies seen on serum testing. For ITP, first-line medical therapy is the use of steroids to prevent the formation of antibodies; 50–75% of adults will respond to the initial use of steroid therapy, but long-term response rates are much lower at 15–20%. If steroids do not improve the symptoms, a recurrence occurs, or serious bleeding occurs, then anti-IgG antibody can be used. In pediatric patients, ITP is self-limited in the majority of patients, especially by the age of 5. Transfusion, steroids, and anti-IgG antibody therapy is usually avoided in pediatric patients unless the patient has life-threatening or symptomatic bleeding. When the platelet count is less than 20,000/mm3 (14,000–44,000/mm3), pediatric patients are at risk for intracranial hemorrhage. By contrast, thrombocytopenic purpura (TTP) causes thrombocytopenia, because the spleen sequesters the platelets and results in splenomegaly. TTP is associated with a low platelet count, hemolytic anemia, neurologic complications, renal failure, mental status changes, and bilateral lower extremity petechiae. Here the diagnosis can be made by blood smear testing, which will show schistocytes, nucleated red blood cells, and basophilic stippling. The treatment is usually plasmapheresis and transfusion of fresh frozen plasma (not platelets), but splenectomy can be considered when the platelet count and symptoms are refractory to plasmapheresis. Splenectomy is curative in only approximately 40% of patients.

Answer 52

C Prior guidelines supported routine elective resection in patients younger than 50 and in patients with 2 or more episodes of uncomplicated diverticulitis. Newer evidence suggests that these groups are not at an increased risk of complications with successive episodes and that the decision to proceed with elective sigmoidectomy should be individualized. An additional recommendation is that colonoscopy be performed within 6–8 weeks after an acute episode of diverticulitis if it is the first episode or if colonoscopy was not performed recently. Although this practice is debated, the concern is that a small subset of patients (1–2%) will in fact have cancer, ischemia, or inflammatory bowel disease. Laparoscopic lavage is gaining popularity as an alternative surgical approach for patients with Hinchey type II and III disease by CT imaging (table 1). The procedure involves laparoscopic examination of the phlegmon and irrigation of the abdomen but no disturbance of the inflammatory process. Drains may or may not be placed. Patients receive antibiotics and are followed clinically. Critics argue that the risk of continuing or recurrent infection is a concern when the septic focus remains. Current data support laparoscopic lavage in Hinchey type III purulent peritonitis, but no supportive data exist for laparoscopic lavage in Hinchey type IV feculent peritonitis. Traditionally, all patients who had an urgent operation for perforated diverticulitis underwent resection with a colostomy. This dogma is now challenged because of the high risk of complications associated with colostomy takedown and colostomy closure rates are much lower than ileostomy closure rates. Thus, colectomy with a primary anastomosis and proximal ileal diversion for Hinchey types III or IV disease may be optimal in select individuals versus subjecting all patients to a routine Hartmann procedure.

Answer 53

A Comparing open and laparoscopic repair of incisional hernias with mesh, there is no difference in the early outcomes of seroma, reoperation (about 13%), readmissions (2%), or mortality (<1%). The risk of recurrence is higher with open repair (approximately 20% vs. 15%). Laparoscopic hernia repair is associated with increased operating room costs (supplies and longer operative times) but has shorter total hospital length of stay compared with open repair. The net effect is that total costs for both procedures are similar.

Answer 54

C Colorectal procedures are associated with a relatively high SSI rate (5–30%). ``` In a Cochrane database analysis of 680 trials involving more than 43,000 patients, the investigators concluded that combined oral and intravenous antibiotic prophylaxis reduced SSI compared with intravenous antibiotics alone or oral antibiotics alone. In a review of elective colorectal procedures using the Veterans Affairs Surgical Quality Improvement Program, 12% of almost 6000 patients developed SSI. Oral plus intravenous antibiotics (n = 2426) had a lower SSI rate than intravenous antibiotics alone (n = 3324; 6.3% vs 16.7%, p 11%). Oral antibiotic use was associated with a lower SSI rate for every class of antibiotics used. ```

Answer 55

E Due to its availability, ease of use, and relatively low cost (compared with MRI), multidetector CT scan (MDCT) is generally the test of choice for screening and staging of liver metastases. These metastases are best detected by dynamic CT scanning during the portovenous phase. Contrast enhanced MRI is the most sensitive imaging modality to detect small (<1 cm) liver lesions due to its superior soft tissue resolution and the ability to use diffusion-weighted imaging. The sensitivity of contrast-enhanced MRI to detect liver metastases is 90–95% compared with 70–75% for MDCT. However, the increased costs and limitations of MRI (e.g., metal implants, claustrophobia) limit its use as a screening tool. The main role of MRI is in detection and characterization of small lesions. In this respect, MRI outperforms both FDG-PET scan PET-CT scan in the detection of small liver metastases. Transabdominal ultrasound fails to detect more than 50% of liver metastases. Contrast-enhanced ultrasound may improve performance; however, this method is not yet available in the United States.

Answer 56

B The most common postoperative complication of distal pancreatectomy is a leak from the cut edge of the pancreas, occurring in 20–30% of patients. To avoid this leak and subsequent development of a pancreatic fistula, many closure techniques and adjuncts were investigated. Direct suture ligation is the most reliable method to reduce pancreatic leak after pancreatectomy. Although initially thought to be promising, stapler transection of the pancreas (with or without stapler reinforcement) does not reduce leak rate. Postoperative pancreatic stent placement might be useful treatment for a known leak; however, prophylactic use of this technique does not reduce leak rate. Routine use of fibrin glue sealant, closed suction drains, and postoperative somatostatin analogue do not reliably reduce leak rates after distal pancreatectomy.

Answer 57

A Patients requiring temporary abdominal closure have significant morbidity and an in-hospital mortality rate of 33%. Complications of open abdomens include abdominal abscesses, enterocutaneous fistulas, and chronic hernias. Eventual closure techniques may include tissue rearrangement and use of biosynthetic agents. Temporary closure of an open abdominal wound is commonly accomplished with a vacuum dressing. When a patient requires open abdomen management, negative pressure therapy is becoming the method of choice, especially in trauma patients and for planned re-exploration in other general and vascular surgery patient populations. Temporary negative pressure abdominal wound closure is associated with patient comfort, low complication rates, and low costs. Eventual primary closure of open abdominal wounds after negative pressure treatment exceeds 70%.

Answer 58

C Asplenic or hyposplenic patients have increased risk for infection and death from encapsulated organisms, often pneumococcus, Haemophilus influenza type b, or meningococcus. However, patients who have a splenectomy to treat an underlying hematologic outcome are at greater risk for postsplenectomy infection. Splenic implants are not considered adequate protection against overwhelming postsplenectomy infection (OPSI).OPSI can progress rapidly from a mild flu-like illness to fulminant sepsis that is fatal in up to 70% of cases with delayed or inadequate treatment. Because of the high mortality and fulminant course associated with OPSI, vaccination and antibiotic prophylaxis are the basis of the management of asplenic or hyposplenic patients Pneumococcal, H. influenzae type b, meningococcal, and influenza virus vaccinations are recommended for asplenic patients, preferably 2 weeks before an elective surgery. A booster dose should be administered every 5 years. Children who receive their dose before age 7 should receive a booster dose 3 years later with subsequent doses every 5 years. Asplenic patients with a fever should receive empirical antimicrobial therapy. Rapid identification of patients at risk for OPSI and administration of vancomycin and ceftriaxone to cover Streptococcus pneumonia, H. influenzae, Neisseria meningitidis, and many community-acquired Gram-negative bacilli can improve survival. Prophylactic antimicrobial therapy is recommended for asplenic children younger than age 5 and may be considered for older children and adults for 1–2 years after splenectomy. Patients who have had postsplenectomy infection should have lifelong prophylaxis. Asplenic patients should be educated about the risk of life-threatening infection with any illness with fever or severe flu-like symptoms without fever.

Answer 59

A Cholecystokinin (CCK) cholescintigraphy is an appropriate step in diagnosing the patient with typical gallbladder symptoms who has a negative ultrasound evaluation. CCK or a synthetic derivative (sincalide) is injected 30–60 minutes after the administration of Tc-99m labeled disofenin (DISIDA, 2,6-diisopropyl acetanilidoiminodiacetic acid) or mebrofenin (BRIDA, bromo-2, 4,6-trimethyl acetanilidoiminodiacetic acid). Imaging starts after the injection and continues for 60 minutes. When acute cholecystitis is suspected and the gallbladder is not seen within 60 minutes, imaging should be continued for up to 3–4 hours. Imaging for 18–24 hours may be necessary in some cases (e.g., a severely ill patient, severe hepatocellular dysfunction, or suspected common bile duct obstruction). If the patient is being studied for a biliary leak, 2- to 4-hour delayed imaging should be obtained. The Society of Nuclear Medicine defines an ejection fraction of less than 38% as abnormal. This is a calculated number designated as 2 standard deviations from the mean and there will be “normal” patients who have ejection fractions less than 38% and abnormal patients who have ejection fractions greater than 38%. Thus, specificity of this test for gallbladder disease is low. The use of CCK cholescintigraphy for diagnosis of biliary tract disease should be limited to those patients who meet ROME III criteria (table 1) for functional gallbladder disorders. It should not be used to evaluate atypical abdominal pain, because many medical conditions, including diabetes, irritable bowel disease, and celiac disease, can produce an abnormal gallbladder ejection fraction. Several medications may reduce gallbladder contractility and should be withheld before the test. These include atropine, calcium channel blockers, octreotide, progesterone, indomethacin, theophylline, benzodiazepines, H2 antagonists, and all opioids. Although many physicians rely on reproduction of the patient’s symptoms by the CCK infusion to recommend cholecystectomy, this is a very nonspecific finding. Several small retrospective studies recommended removal of the gallbladder for symptoms induced by CCK infusion, but at this time it is not considered a reliable test for the effectiveness of cholecystectomy in curing symptoms. Reproduction of symptoms is quite often the result of rapid infusion of the CCK analog.

Answer 60

D The most appropriate time to (semi-) electively operate on a pregnant women with cholecystitis is in the second trimester (13–26 weeks), because there is a lower incidence of premature labor compared with the third trimester. At 32 weeks, conservative management of her cholecystitis should be attempted initially. If an operation is mandated, the mother should be pretreated with betamethasone 24 hours and 12 hours preoperatively. This approach enhances surfactant production and reduces the need for neonatal respiratory support. At 32 weeks, any radiographs that are clinically needed are safe. This includes intraoperative cholangiography as well as endoscopic retrograde cholangiopancreatography (ERCP). The fetus should be shielded when possible. External fetal monitoring is indicated. Laparoscopic surgery is as safe or safer than an open procedure in pregnancy. An open cutdown to the peritoneal cavity is indicated (Hasson technique). Gallstone pancreatitis is associated with a fetal loss of 4.7% compared with a fetal loss of 2.8% with non–gallstone pancreatitis. A patient with gallstone pancreatitis should be treated with a cholecystectomy and clearing of stones with operative common duct exploration or postoperative ERCP. Both are associated with lower rates of fetal loss than conservative management.

Answer 61

E The only definitive treatment for end-stage hepatic failure is liver transplantation. Portacaval shunting, splenorenal shunting, and a transjugular intrahepatic portosystemic shunt (TIPS) will all reduce portal hypertension, which will reduce gastrointestinal bleeding, but they do not treat the underlying liver failure and will exacerbate encephalopathy. Although protein restriction was previously recommended for hepatic encephalopathy, it is no longer indicated and may be harmful. High-protein diets are well tolerated in patients with cirrhosis; they should receive 1–1.5 g/kg of protein and 25–40 kCal/kg per day. Most patients with cirrhosis have a deficiency of branched chain amino acids. These are commonly found in dairy products and vegetables. Augmentation of the diet with these proteins may be useful. Although there is anecdotal evidence in favor of the use of purgative agents such as nonabsorbable disaccharides (such as lactulose), no comprehensive meta-analysis has shown them to be effective.

Answer 62

A This patient has clinical evidence of familial adenomatous polyposis (FAP). Patients with classic FAP are at high risk of developing abdominal desmoid tumors, occurring in approximately 10–15% of patients with FAP. Attenuated FAP is a subtype and recognized by fewer polyps, presentation at an older age and less risk for developing desmoid tumors. Desmoid tumors are considered benign, because they do not metastasize. However, despite having a benign designation, abdominal desmoid tumors can cause significant local problems as they grow into surrounding tissues. Therefore, while considered “benign,” some abdominal desmoid tumors clearly have a “malignant” effect on patient’s lives and can result in death. The natural history of these tumors is unpredictable, with a small number regressing completely, some waxing and waning, many staying stable over time, and a small number rapidly progressing. The management of these lesions is multidisciplinary. Surgery is reserved for tumors that are symptomatic and resectable, because recurrence is common. Simple observation is reasonable for small, asymptomatic lesions. As part of this strategy, serial CT scans to identify complications, such as ureteral obstruction, is reasonable. First-line pharmacologic agents include nonsteroidal anti-inflammatory medications (e.g., sulindac) and antiestrogens (e.g., tamoxifen). Cytotoxic agents can be used for advanced disease that is not responding to these other, less-toxic choices. Surgery is often complicated and associated with frequent complications. Therefore, it is done only for significant symptoms. When necessary, resection is the best option if possible. However, many patients will have unresectable disease, so a bypass can be done to relieve a bowel obstruction. This patient has an incidental finding of a mesenteric mass. While at risk for metastatic colon cancer, the biopsy is most consistent with a desmoid tumor. Resection is not indicated at this time and should not be done. Imatinib is a tyrosine kinase inhibitor used to treat gastrointestinal stromal tumors. FOLFOX (5-fluorouracil, leucovorin, and oxaliplatin) is a combination chemotherapeutic regimen used for the adjuvant treatment of colon cancer. Radiation is not used in the treatment of desmoid tumors, because it appears ineffective and is associated with a high rate of complications. Therefore, sulindac is the best option at this time.

Answer 63

C Acute portal vein thrombosis often presents with onset of vague abdominal pain. Imaging studies such as CT will typically define the significance of the abnormality. In most patients, the portal vein and its tributaries and branches are involved. One study found that more than 50% of the patients had a prothrombotic state, and 35% had a myeloproliferative disorder as a precipitating factor in the development of portal vein thrombosis. Imaging often shows ascites, but it is rarely clinically significant. Gastroesophageal varices develop in up to 50% of patients without recanalization, although this is rarely an initial presentation. Studies suggest that gastroesophageal varices may develop as early as a month after thrombosis but more commonly develop later over time. Early anticoagulation is associated with recanalization in 40% of patients studied, but no patients recanalized when anticoagulation was not used. Another study found similar findings in patients who underwent early anticoagulation that continued for a mean of 8 months; 39% patients developed recanalization. Early anticoagulation of patients with acute portal vein thrombosis leads to a better outcome with a reduced risk of gastrointestinal complications.

Answer 64

D This patient presents with acute symptoms related to her polycystic liver disease. Indications for intervention include acute pain from potential bleeding into the cyst, vague mass effect from the size of the cyst, and, rarely, liver dysfunction. Fenestration is most effective, can be done laparoscopically, and often is performed as an outpatient procedure. There is minimal risk of bleeding or postoperative complications with this approach. Hepatic resection is not necessary in the management of this disease. Sclerotherapy is ineffective with a high rate of recurrence. Observational studies suggest that pregnancy and estrogen replacement therapy can increase the number and volume of cysts. Somatostatin analogues may reduce the overall volume of the liver but have no effect on the size of the cysts.

Answer 65

E The management of acute necrotizing pancreatitis continues to evolve. A multitude of different modalities are now available that affect the timing and management approach for patients with walled-off pancreatic necrosis (WOPN). This patient continues to be symptomatic a month after his acute process. The CT scan suggests a small fleck of air in one of the pockets of the WOPN Expectant management of this patient may continue to work, although his recovery is likely to be slow. The gas within the fluid collection raises concern for bacterial contamination and infection. There is not an obvious endoscopic site for transluminal drainage of this fluid collection, and the multiple loculated areas would make this less likely to work effectively. Percutaneous aspiration is a diagnostic test to exclude an infected fluid collection. Percutaneous drainage is possible and may expedite resolution of the patient’s symptoms, but often the material cannot be completely evacuated. Laparoscopic debridement runs the risk of further seeding infected fluid throughout the peritoneal cavity, which would be less than ideal. Direct percutaneous endoscopic debridement, also referred to as direct retroperitoneal debridement, offers an excellent option for management of this process. The procedure uses laparoscopic instruments passed in a retroperitoneal plane into the cavity for debridement and irrigation or direct percutaneous endoscopic debridement. This procedure is usually facilitated by first passing image-guided catheters into the cavity and using these catheter tracks to guide the laparoscopic instruments. Endoscopic debridement was used in this patient with prompt resolution of the symptoms and no need for subsequent operative intervention.

Answer 66

E The Child-Turcotte-Pugh (CTP) score was originally developed to evaluate the risk of portocaval shunting procedures in patients with portal hypertension. It is also used to evaluate surgical risk in other intra-abdominal procedures performed in cirrhotic patients. Overall surgical mortality is 10% for patients with class A cirrhosis, 30% for those with class B cirrhosis, and 75–80% for those with class C cirrhosis. Components of the CTP score are international normalized ratio (INR), bilirubin level, albumin level, encephalopathy, and ascites (table 1). The CTP score is criticized for its 2 subjective variables (degree of encephalopathy and ascites), narrow range (5–15), and the equal weight given to each variable. The Model for End-Stage Liver Disease (MELD) is a linear regression model based on 3 laboratory values (INR, bilirubin, and creatinine level). It was initially developed as a model to predict mortality after transjugular intrahepatic portosystemic shunt but has now become the method used for liver transplant allocation in the United States. The MELD formula is shown in figure 1. MELD is an excellent predictor of postoperative mortality. One study demonstrated an increase in mortality of 1% for each MELD point, up to a score of 20, and by 2% for each MELD point above 20. Cirrhotic patients undergoing urgent surgery or major operations have a relative risk of mortality increase of 14% for each 1-point score in their MELD score (figure 2). Both the CTP and MELD scoring systems use INR and total bilirubin in their calculation.

Answer 67

E This patient presents with a small bowel obstruction secondary to an obturator hernia. An obturator hernia is a rare pelvic hernia with an incidence of approximately 1%. A weakening of the obturator membrane can result in an enlargement of the obturator canal and herniation of small bowel contents adjacent to the obturator vessels and nerve, leading to an obstruction. Obturator hernias are most commonly seen in elderly women with prior weight loss and no history of abdominal surgery. Patients can present with signs of a small bowel obstruction: nausea, vomiting, obstipation, and abdominal pain. Thigh or knee pain on the affected side are commonly seen. The Howship-Romberg sign refers to ipsilateral groin pain radiating down the thigh caused by irritation of the obturator nerve. The referred pain is relieved by flexion of the thigh and aggravated by extension, abduction, and medial rotation. This patient presents with signs of compromised bowel, tenderness on exam, and an elevated white blood cell count. Therefore, observation would not be appropriate management. Surgery through a midline incision is preferred for an obturator hernia, because it gives the best exposure, allows reduction of hernia content, and facilitates bowel resection if necessary. Resection of the involved portion of the bowel is sometimes required because of gangrenous changes or perforation. The defect in the membrane can usually be closed with interrupted nonabsorbable sutures. On occasion, a mesh repair is required. An obturator hernia cannot be repaired through a femoral or inguinal groin exploration. In this patient with signs of compromised bowel, a preperitoneal approach is not recommended.

Answer 68

C The CT scan of the chest reveals a left diaphragmatic hernia most likely through the previous site of injury. The patient presents with symptoms of a bowel obstruction, abnormal vital signs, and an elevated white blood cell count. The suspicion for strangulated bowel is high. The patient will need an exploration to reduce the bowel, a resection if the bowel is indeed gangrenous, and repair of the diaphragm. This can best be accomplished through an abdominal incision using a midline exploratory laparotomy. The thoracotomy incision, whether anterolateral or posterolateral, would make abdominal exploration of the bowel with possible resection quite challenging. There is no role for placement of a chest tube or upper endoscopy in this patient, who presents with a strangulated diaphragmatic hernia.

Answer 69

D Acute calculous cholecystitis is a common surgical emergency, often affecting elderly patients and those with serious medical comorbidities. Emergency cholecystectomy in this high-risk group of patients is associated with increased morbidity up to 41% and with mortality up to 4.5%. An alternative treatment is image-guided percutaneous cholecystostomy under local anesthetic, which has less morbidity and mortality than open or even laparoscopic cholecystectomy in the emergency setting. Once the acute episode is resolved, cholecystectomy may or may not be considered as an elective intervention.

Answer 70

B Liver metastases from colorectal cancer are the most frequent hepatic malignancies in the United States. Radiofrequency ablation (RFA) is a local therapy that uses a form of alternating electrical current to achieve thermal destruction. RFA is performed using several techniques: percutaneous, open, or laparoscopic. Tumor size and location can preclude effective RFA when used as curative treatment. Tumor sizes larger than 4–5 cm are associated with an increased incidence of recurrence. Traditionally, the presence of 4 or more hepatic metastases was a contraindication to hepatectomy. Current data reveal that hepatectomy for 4 or more metastases is associated with an approximate 5-year survival rate of 33%. Resectability is based on volume of liver remaining after resection and not the actual number of tumors. In a patient with normal liver function, a 20% remnant is recommended. In a patient who has undergone neoadjuvant chemotherapy, a 33% remnant is recommended. Neoadjuvant chemotherapy can yield good results when used for multiple colorectal metastases. Chemotherapy and complete resection of hepatic metastases are associated with long-term survival in up to 50–60% of patients.

Answer 71

B This patient has acalculous cholecystitis, and no further imaging is necessary to confirm the diagnosis. Acalculous cholecystitis is typically associated with critical illness, and most of these patients are poor surgical candidates. Mortality associated with this disease is 41%. Acalculous cholecystitis is generally the result of biliary stasis and gallbladder ischemia, although the pathophysiology is incompletely understood. Stasis is frequently due to prolonged fasting or hyperalimentation. Progression of disease with gallbladder complications, such as perforation, gangrenous cholecystitis, or emphysematous cholecystitis, occurs in 40–100% of these patients; therefore, observation alone is not recommended. Magnetic resonance cholangiopancreatography or endoscopic retrograde cholangiopancreatography would not benefit this patient, because the common bile duct is normal in caliber and gallbladder inflammation and ischemia is the source of her sepsis. Percutaneous cholecystostomy is recommended as definitive therapy or as a bridge to ultimate cholecystectomy when the patient is medically stable. In a hemodynamically normal patient, most authors recommend a laparoscopic approach initially rather than an open approach given the proven safety and decreased hospital length of stay of the former.

Answer 72

E Indirect hernias are associated with a patent processus vaginalis. Patients with a patent processus vaginalis have a lifetime incidence of inguinal hernia of 5%. Direct hernias occur in an anatomic area called Hesselbach triangle, which is bordered by the inguinal ligament inferiorly, the inferior epigastric vessels laterally, and the lateral edge of the rectus medially. Femoral hernias occur inferior to the inguinal ligament and medial to the inferior epigastric vessels and are more common in women than men. The most commonly occurring hernia in female patients, however, is an indirect inguinal hernia. During inguinal hernia repair, the most commonly injured nerve is the ilioinguinal. This nerve is close to the external inguinal ring and is a sensory nerve to the pubic region and the upper portion of the scrotum or labia majora. The genital branch of the genitofemoral passes with the spermatic cord to the scrotum, and the lateral branch forms the lateral femoral cutaneous nerve and provides sensation to the lateral portion of the anterior thigh. Although most series report chronic pain limiting quality of life as occurring in only 5% of postoperative hernia repair patients, up to 30% of patients report some long-term pain or discomfort when asked on a confidential questionnaire. Chronic pain may persist for several years and is the most serious long-term complication.

Answer 73

C Inguinal herniorrhaphy is one of the most commonly performed surgical procedures today. Incidence of “groin hernias” is substantially higher in male patients (2–5% vs 0.3% in women). Although femoral hernias comprise only a small minority of groin hernias in men, they represent nearly one-third of the groin hernias in women. After open mesh repair, a “recurrence” in women is often seen in the femoral canal. The most likely explanation is that these are not recurrences but rather errors in diagnosis leading to the incorrect operation. A traditional, open, tension-free, mesh repair (Lichtenstein) will address both the direct and indirect defects but does not cover the femoral canal. Both McVay and open preperitoneal repairs will address the femoral canal, but these are less commonly performed than open Lichtenstein procedures. A laparoscopic, extraperitoneal herniorrhaphy allows for exploration and coverage of the entire myopectineal orifice, addressing both inguinal and femoral hernias. In women, laparoscopic preperitoneal repair is associated with a lower recurrence rate than open mesh repair.

Answer 74

E Management of asymptomatic or minimally symptomatic hernias is evolving as long-term randomized controlled study data for watchful waiting are reported. Since their original report in 2004 demonstrating safety of watchful waiting during short-term follow-up (median 3.2 years), Fitzgibbons et al. followed patients up to 11.5 years and found that the overall crossover rate to surgery is 68%. Men older than 65 are significantly more likely to crossover to surgery than are younger men (79% vs 62%). The most common reason for surgery was pain (54%). Only 2.4% of watchful waiting patients required emergency operation for complications such as strangulation or obstruction. The authors concluded that watchful waiting is therefore safe, regardless of the timing of onset of the hernia, presence of a bulge, or age of the patient, but most patients will experience a progression of symptoms and ultimately need surgical repair. A similar study in the United Kingdom found that 72% of the watchful waiting cohort came to operative therapy at 7.5 years of follow-up.

Answer 75

C In the United States, nonparasitic splenic cysts may be posttraumatic or primary (figure 1). Rupture of splenic cysts either spontaneously or posttraumatically is rare. Studies suggest that fewer than 60% of posttraumatic cysts are symptomatic. Few data support the use of cyst size as an indication for splenectomies in asymptomatic patients. Postaspiration cyst and symptom recurrence are very common; however, symptomatic relief with aspiration can suggest a benefit of operative management of splenic cysts. Because of the benign nature of the majority of splenic cysts, partial splenectomies or partial cystectomies (unroofing) are reported in most patients.

Answer 76

A These lesions are too small for bx and may be granulomas. Monitor lung findings closely with follow up CTs For high or low grade soft tissue sarcomas of the extremities, combined modality local therapy of surgery with radiation is standard of care. Radiation improves both local recurrence and relapse free survival compared with surgery alone. Particularly true when resection margins are close (<1 cm) b/c they are likely to be based on proximity of tumor to the femoral neurovascular bundle. Local control and survival with limb sparing surgery is similar whether radiation is given preop or postop. Pre op radiation allows for smaller, more precise fields, but this may come at the trade off of more wound complications.

Answer 77

D Predicted by location Anterior mediastinal masses--thymic neoplasms, germ cell tumors, lymphoma and teratoma as well as thyroid and parathyroid pathology Middle mediastinal masses--lymphomas, granulomas, and cystic processes such as congenital aerodigestive tract cysts of pericardial cysts. ~30% malignant Posterior mediastinal masses--neurogenic, esophageal masses and neurenteric cytsts, with relatively few of these being malignant. Nerve sheath tumors compreise 40-65% of neurogenic tumors in chest, and ~75% are schwanommas. Typically firm and encapsulated. On CT they are round and well circumscribed. Low malignant potential. Observation is appropriate unless high risk features including symptoms, >5 cm, hx of radiation in field or evidence of invasion on CT or MRI. Neuroblastoma is much more common in childhood and would be rare in this patient

Answer 78

C Up to 5% of pancreatic tumors in referral centers Symptoms of acute, chronic or relapsing pancreatitis Classic view on ERCP is fish mouth pancreatic duct opening with mucinous fluid emanating from it. Pancreatic adenoca would not present with these ERCP findings. S &S are non specific but can include new abdo/back pain, wt loss (often significant), steatorrhea, and loss of appetite. Pain can be sign of locally advanced disease. Painless jaundice is the classic presentation for lesions in the head of the pancreas. 4th leading cause of cancer death in US. Only 15-20% of patients dx with panc adenoca are candidate for panc resection. CT for diagnosis and preop staging. In addition to determining primary tumor size, CT is used to evaluate invasion into local structures and for evidence of mets Cystadenoma can cause pacnreatitis but these are more commonly found incidentally when imaging is done for abdo pain. These cysts are typically found in the 5th-6th decade and they are located in the body or tail of the pancreas.

Answer 79

C Three main types of IPMN-- Main branch, mixed and branch type. Main duct has far greater malignant potential than branch duct. In diffuse main duct, total pancreatectomy is required for cure. When resection is done for branch type, local recurrence is 8%. Further, after resection of branch type, development elsewhere in N pancreas is uncommon. Although diffuse involvement can be seen, multifocal presentation is uncommon. If left unresected, IPMNs follow a dysplasia carcinoma sequence undergoing malignant transformation and invasion, which ultimately disseminate and spread. WU includes MRCP, EUS with aspiration of fluid and assessment of specific duct types involved. Observation may be appropriate for in patients without consensus indication for resection. Consensus indication include main duct or mixed type IPMN, b/c they have a risk of malignancy approaching 70%. Further branch type IPMN with the presence of symp, mural nodules or cysts >3 cm If abN appear focally limited, local resection with pancreatic head or tail resection can be considered. Frozen section should be done of the margin of resection. If there is carcinoma or carcinoma in situ, additional resection or completion pancreatectomy should ensue. If resection margins show only adenomatous changes or less, observation may ensue.

Answer 80

E Arise from interstitial cells of Cajal, the intestinal pacemaker cells. Most common connective tissue tumors affecting GI tract. Most commonly located in stomach and proximal small bowel. Standard of care is complete surgical resection, either open or laparoscopic. No evidence that large organ resections are of benefit. Avoid rupture and tumor spillage b/c this increases the risk for recurrence. Lymphadenectomy not indicated b/c GISTS rarely met to locoregional nodes. Spread is hematogenous and most common site is the liver. In addition, peritoneum is a common site of locoregional mets, presumably due to drop mets. Resection remains mainstay and initial choice of treatment for GISTs that cab be completely removed Preop imatinib not indicated for resectable disease but may be useful in marginally resectable patient in an effort to make them resectable or ensure margin neg resection. Risk of recurrence and need for adjuvant therapy is estimated by the size of the tumor, its mitotic indexx, and the site of origin of the tumor. Radiation is not indicated in patients with resectable disease or in other patients b/c there is no evidnece that it is radiosensitive. Standard cytotoxic chemo is inefffective.

Answer 81

B Meckels is a congenital remnant of omphalomesenteric duct. 1-2%. Most common anomaly of GI tract. Incidence of malignancy in asymptomatic Meckel's is 0.5% and 3% in symptomatic. Most common primary malignant tumor found within a Meckel's diverticulum is carcinoid (76.5%). Remaining types include adenoca (11.4%), GIST (10.8%), and lymphoma (1.3%). Although heterotopic gastric or pancreatic tissue may be found in a Meckel's diverticulum, pancreatoblastoma is not reported Surgical management of asymp Meckel's is controversial. Factors assoc with symp included age <50, male, diverticulum length > 2 cm, and palpable ectopic tissue or abN features of diverticulum. Most common site of ileal malignancy is a Meckel diverticulum and survival is related to stage of disease. Overall incidence rate of Meckel diverticular malignancy is low, an incidentally discovered Meckel diverticulum represents a high risk anatomic region whose risk increases with age. Therefore a Meckel diverticulum discovered intraop should be resected as a method of absolute cancer risk reduction give the high possibility of curative resection and negligible operative mortality, especially in younger pts.

Answer 82

E Stenting used as definitive palliative procedure or as a bridge to surgery. Technical success with stenting was 96.2% with a perforation rate of 4.5% and reobstruction rate of 12%. Shorter hospital stays with stent placement than emergency surgery. Primary anastomosis rates were 2x greater with stenting than emergency operation. Complications were higher in emergency surgery group than stent group. Stenting followed by lap resection of obstructing colorectal ca demonstrated lower blood loss, lower post op analgesia requirements, lower surgical site infection rate and lower rate of anast leak after primary anast. More LNs were present in the specimens in pts treated with stenting followed by elective lap resection compared to open surgery. Stenting does not delay initiation of chemo. However when stenting alone is used as definitive palliation in patients also receiving high dose chemo, there may be an increased risk of delayed perf secondary to tumor shrinkage

Answer 83

B In patients with localized melanoma, tumor thickness, mitotic rate, and ulceration were the most significant prognostic factors. Assoc betwee patient age, tumor thickness and ulceration: with incr age, tumor thickness and ulceration incr. In addition, proportion of male patients with melanoma incr with age. However, age by itself, is not as powerful of predictor of survival as is tumor thickness, ulceration and mitotic rate. Anatomic sites for melanoma assoc with least favorable prognosis include the scalp and neck. Women have better overall survival rates than do men with melanoma

Answer 84

A In up to 1/4 of patients undergoing resection of their primary, the liver is the only site of initial recurrence. Median survival in untx pts with hep mets is < 1 yr, 5 yr survival can approach 25% after resection in select pts. ``` FONG criteria >Five cm 200 Extrahepatic disease Postive margin ```

Answer 85

C BCC is most common form of skin cancer, predominantly in men > 40 y.o. Arises most often in sun expsoed skin (eg. face) in susceptible populations (i.e. fair skinned, blonde hair, blue eyed people) living in regions of high sun exposure. Slow growing tumor that rarely mets but its insidious nature can lead to extensive regional infiltration and destruction. Many variants exist. 2 main classifications: circumscribed and diffuse. Nodular BCC, variant of circumscribed, is the most common. Presents as dome-shaped, pearly lesion with distinct borders. Morpheaform, a diffuse form, is particularly aggressive and can be a tx challenge. Presents as whitish, plaque like lesion with poorly defined margins. On path, it has elongating strands of BCC infiltrating the dermis Tx tailored to type of lesion and its location. Small lesions, curettage and electrodisssection in the office with 2-3 mm margins often renders excellent results. It cannot be used for morpheaform BCC or other deeply infiltrating lesions. Surgical excision with or without reconstruction is indicated for large tumors, invasion of tumor into surrounding structures, and aggressive histologic types (e.g. morpheaform, infiltrative, and basosquamous BCC)> Margins should be 5-10 mm. With BCC of favorable histology located in areas of aesthetic concern, Mohs sx can be performed. Form of minimal resection with immediate pathologic frozen confirmation of neg margins that minimizes the defect created. Radiotherapy is an option in tumors that cannot be excised or in tumors that have incomplete excision. Should not be used in patients < 40 y.o. except in unusual circumstances. Topical therapy with imiquimod is an option in patients with superficial or nodular BCC, but it requires long term administration and excellent patient compliance

Answer 86

A Rare form of gastric neoplasm (4% of all gastric cancers), it remains the most common form of extranodal lymphoma (up to 20% of all such malignancies). N stomach is typically devoid of lymph cells; chronic inflamm from H pyloir infection, however, leads to acquisition of mucosa assoc lymphoid tissue (MALT) within the stomach, with subsequent degeneration into initial low grade then subsequent high grade lymphoma. Typically B cell tumors. Dx is made by endoscopic bx of lesions. WU include EUS, CT CAP and bone marrow bx to r/o extragastric disease or secondary gastric involvement. Low grade MALT lymphoma isolated to the stomach is tx through eradication of gastric H pyloric infection. With it, the lymphoma is often cured. Therapy must combine acid suppression with antibiotics. PPIs, H2 receptor blockers and bismuth slats are used to help control gastric acid. Administration of 2 Abx is more effective than 1 alone. Most common Abx used include clarithryomycin, amoxicillin, metronidazole, or tinidazole. In patients with persistent MALT lymphoma after successful eradication of H pylori, radiation is often used. High grade primary gastric lymphomas are tx with chemorads. Surgery tx of primary gastric lymphoma, once the mainstay, is now reserved for tx of complications such as perforation, bleeding or obstruction. If undertaken in patients with disease limited to stomach and regional LNs, a radical subtotal gastrectomy with D2 dissection can be performed. Palliative gastrectomy is also an option in patients with extragastric disease. Wedge excisions are not performed.

Answer 87

C.. although not true these days. HIPEC is done with resection of CRC liver met GI peritoneal carcinomatosis is rare. Natural hx is variable and dependent on subtype. Role of peritonectomy and peritoneal chemo remains unclear, and benefits cannot be generalized across all diagnoses. Therapy can be morbid and the palliation and survival advantages are obscured by non standard diagnostic definitions, tx protocols and lack of prospective studied. Presence of solid organ mets is a contraindication to surgical mgmt of peritoneum, b/c this presentation defines a malignant and aggressive natural hx. Std definition for optimal debulking is elusive and not assoc with improved survival Pseudomyoxma peritonei should be classified into at least 2 general subtypes: disseminated peritoneal adenomucinosis (DPAM) and peritoneal mucinous carcinomatosis (PMCA). These 2 descriptions represent a spectrum and there is room for intermediate tumor types. Appendiceal primary tumors tend to fall into a more indolent natural hx than colon primaries. Median survival for appendiceal PC can excess 6 yrs. Dx of DPAM is best used to describe these lesions. DPAM is characterized histologically by abundant extracellular mucin containing scant simple to focally proliferative mucinous epithelium with little cytologic atypia or mitotic activity and is usually associated with appendiceal mucious adenoma. Colon primaries tend to be more sinister, with a median survival of less than 2 years. PMCA is the more typical histological subtype here. PMCA is composed of more abundant mucinous epithelium with the architectural and cytologic features of carcinoma

Answer 88

D Effective chemo regimens have led to improvements in medial survival of patients with stage IV colon ca (approx 12 months 20 yrs ago to 24 months now). For patients with mets confined to liver, these chemo regimens used in the neoadj setting have incr the number of patients with borderline disease who may benefit from liver resection. First line multiagent therapy FOLFOX is assoc with an expected response rate of 70%. Response to therapy is an important stratification tool for patients with advanced but potentially resectable disease. Pts who fail to respond to chemo have poor prognosis. Multiagent chemo is not assoc with incr morbidity after resection PET are metabolic studies and depend on avidity of tumor cells to concentrate the glucose agent. Tumors can be viable yet not sufficiently metabolically active to show on PET. Complete response on PET is not indicative of complete tumor resolution. CT is highly sensitive, even for small tumors. Some patients (<10%) demonstrate a complete radiographic response--no detectable disease on PET or CT/MRI Several small retrospective studies of patients with a radiographic complete response show fewer than 15% achieve a complete pathological response. Therefore resection is still recommended, even for pts with a complete radiographic response. The resection should use anatomic landmarks from the tumor pretreatment studies to guide resection with a goal of obtaining an R0 outcome.

Answer 89

E Liver directed therapies in patients with cirrhosis are often limited by degree of underlying liver disease. Resection is gold standard for pts with preserved liver function. Patient has stage II HCC lesion amenable to resection of seg 6 and 7, which represent 25% of total liver volume Liver transplant would be considered for this clinical stage II HCC patient but the tumor size and assoc cirrhosis are relative contraindication. ETOH use would be relevant as well and abstinence < 6 months is a contraindication to transplant. Other liver directed therapies should be considered but none can be offered with curative intent. RFA is unreliable in tumors >3 cm with an expected locatl tx failure rate >30% for 5 cm tumors. Role for TACE would be to tx a locally advanced, unresectable tumor and manage lesions with assoc pain or rupture. Sorafenib is a tyrosine kinase inhibitor that modestly improves survival in patients with advanced liver disease and multifocal HCC. Cytotoxic chemos are of limited benefit in HCC

Answer 90

D Incidental gallbladder cancer confined to mucosa is T1a and cured by the chole alone. However, if the gallbladder is removed piecemeal, risk of peritoneal dissemination is high. Tumor invading serosa is T2. These patients have a demonstrated survival benefit after completion extended chole--resection of seg IVb and 5 of liver and portal lymphadenectomy. Patients with more advanced disease, remote lymphadenopathy, peritoneal studding or hepatic mets do not derive benefit from complete radical resection. Peritoneal or liver mets define stage IV disease and are contraindications to further surgery

Answer 91

E Neutropenic enterocolitis or typhlitis is a relatively uncommon complication of chemo. It is transmural inflammation of the bowel, usually affecting the ileocecal region. Pathogenesis not fully elucidated, may be related to an acute mucosal injury with secondary infection. Usually assoc with chemo for hematologic malignancies, bone marrow transplant, and high dose chemo in solid tumors. Pooled incidence 5%. Agents include taxanes, cisplatin, oxaliplatin, irinotecan, anthracyclines, gemcitabine, vinorelbine, and 5-FU. Typical presentation is neutropenic patients with fevers and abdo pain. Most reliable diagnostic test is CT scan. Usually show colonic mural thickening, pericolic inflammation, pneumatosis intestinalis and ascites Without absolute indications for sx, such as perforation or peritonitis, management is usually conservative, with broad spectrum Abx and observation, bowel rest, NG tube if N/V, hydration and TPN. Some physicians have recommended GCSF to reverse neutropenia. B/c chemo is the underlying cause, continued chemo is contraindicated. Sx is indicated in perforation, such as free air on AXR, or continued clinical deterioration. If sx is indicated, removal of all gangrenous bowel is necessary and extent of resection will depend on findings. In this patient, operation is not indicated, therefore, neither appy nor R hemi is appropriate. Colonoscopic decompression is used for Ogilvie or colonic volvulus and is not treatment fore neutropenic enterocolitis.

Answer 92

D He has T3N1M1 or Stage 4 disease. Even an uncomplicated immediate surgical resection will delay the initiation of systemic therapy and given the locale, would necessitate an APR with permanent colostomy. Diverting colostomy is not necessary since he is not obstructed. In the absence of obstruction, tx should focus on treating his systemic disease; initiation of neoadjuvant chemoradiation is first step in management. Potential benefits include decr toxicity and incr likelihood of patient completion of full tx course. Rationale for concurrent therapy lies in potentiation of tumor radiosensitivity. Addition of oxaliplatin or irinotectan to 5FU and leucovorin has led to clinically significant downsizing of inititally unresectable disease.

Answer 93

C Most sporadic tumors result from chromosomal instability and acquired loss of specific genes. >90% of CRC are sporadic and can be traced to erros in cell cycle transcription due to loss of adenomatous polyposis coli (APC) gene and dysregulation of beta catenin. Small percent of inherited colorectal cancers (1%) arise secondary to germline mutations in the APC gene and are assoc with FAP Microsatellites are simple repetitive sequences scattered throughout the genome; failure of mistmatch repair genes result in microsatellite instability. Identification of MSI is generally assoc with a better prognosis than chromosomal instability. Lynch syndrome is an example of inherited germline mutation in 1 such mismatch repair gene. Polyps in these patients are endoscopically indistinguishable from conventional adenomas but have complete loss of expression of a single mismatch gene in up to 88% of adenomas. Although a dx of Lynch cannot be made w/o genetic testing, screening by immunohistochemistry for MSH2 confers a presumptive dx. In addition, BRAF mutations are present in 40-50% of sporadic tumors due to MSI but are absent in Lynch K-ras mutation are less responsive to epidermal growth factor receptor antibodies (anti-EGFR therapy), such as cetuximab or panitumumab, compared with patients with wild type K rase tumors. 30-40% of CRC harbor a K ras mutation. BRAF mutations are also assoc w/resistance to anti-EGFR regimens but are mutually exclusive of K ras mutations.

Answer 94

B Significant survival benefit for neoadj chemorads followed by surgical resection compared to surgery alone in patients with stage 1-3 adenoca of the esophagus.

Answer 95

C Tx of cutaneous melanoma incl excision of primary lesion along with assessment of nodal status in select pts. LN involvement is most important prognostic predictor of outcome in patients with clinically localized melanoma. Appropriate margins of excision are dictated by the depth of the lesion. Thin melanomas (<1 mm) should be excised with 1 cm margins. Intermediate melanomas (1-4 mm) should be excised with 1-2 cm margins. Thick melanomas (>4 mm) should be excised with 2 cm margins. Wider excision margins do not improve disease free or overall survival SLNB is recommended for intermediate thickness melanomas with clinically neg nodal basins. Given the low risk of nodal mets, SLNB is not routinely recommended for thin melanomas. Likelihood of nodal mets increases in the setting of primary tumor ulceration, mitoses >1 and Clark level IV or V. Thus SLNB is recommended for lesions with these characteristics regardless of thickness <1 mm

Answer 96

A De novo germline mutation is an alteration in a gene that is present for the first time in 1 family member as a result of a mutation in a germ cell (egg or sperm) of 1 of the parents. De novo germline mutations in MLH1 are rare and assoc with a younger age at CRC dx. PMS2 staining is often absent when there is loss MLH1 expression. However, germline mutations in PMS2 gene are most often assoc with absence of PMS 2 only as seen in immunohistochem testing. ~15% of sporadic CRC display high level MSI, mostly due to somatic BRAF V600E mutation. This is not inherited but rather an acquired mutation. Further, presence of BRAF V600E mutation suggests a non inherited process Lynch syndrome is an autosomal dominant cancer predisposition syndrome with mutations in various DNA mismatch repair genes (MSH2, MLH1, MSH6, PMS2). In addition to CRC, it infers incr risk for endometrial ca, ovarian ca, stomach ca, and other types of ca. Screening includes MSI and IHC testing to detect MMR defects in tumor, which determines whether further germline genetic testing is required. BRAF V600E is not observed in tumors from patients with Lynch Colorectal tumors with Kras mutations are not responsive to anti-EGFR based tx. Therefore this patient who is wild type for KRAS may be a candidate for anti-EGFR therapy.

Answer 97

D EtOh and chronic hep C are the most commonly recognized RF contributing to cirrhosis and subsequent HCC, less common hepatic abN are also assoc with potential development of liver malignancy. Glycogen storage diseases have a reported incidence of 22-75% for hepatic adenomas. This incidence appears to incr with patient age but has been reported for patient 3-54 years. Adenomas carry the risk of malignant degeneration and most series report a 5-7% rate of malignancy. Patients with GSD should therefore be surveyed with liver US. Optimizing metabolic control with intensive dietary treatment may prevent occurrence or progression of adenomas and subsequent risk of malignancy FNH has a reported freq of 3% in adults. Typically found incidentally in young women (8:1 F:M). Asymp in 80% of cases and hold no malignant risk. Hemangioma is most common benign lesion of liver with 5-20% prevalence. Few are symptomatic however when they are large >4cm, they may cause pain from capsular stretch. Rupture is rarely reported and they have no malignant potential. Echinococcal liver disease (hydatid) is caused by the larval cestode Echinococcus granulosus. Dogs are the definitive host, and sheep are the intermediate host, with man incidentally infected. Patients are infected early in childhood, and the infection may go undetected for years. Lesions may present with central necrosis and resemble HCC or large hemangiomas. Does not display delayed peripheral asym enhancement on CT. Surgical resection is preferred. No malignant risk. Alternative to sx is percutaneous aspiration combined with oral albendazole or mebendazole for patients who are poor surgical candidates. Peliosis hepatitis is a benign disorder characterized by blood filled cystic cavities. Etiology unknown. Assoc with anabolic steroids and OCP use. Clinical course is benign. Typically resolved once offending drug is d/c'ed. May rupture, hemorrhage and liver failure but carries no malignant risk.

Answer 98

B IPMNs account for 50% of incidentally found panc cysts and 7% of panc malignancies. Divided into main and side branch groups based on imaging with CT or MRCP. Dilation of main duct >1 cm strongly suggests main duct IPMN, whereas a panc cyst communicating with the duct without main duct diln sugguests side branch IPMN. Main duct and side duct have significant diff in prevalence of cancer. Main duct IPMN should be resect b/c of high incidence of malignancy. Side branch is based on level of suspicion for malignancy. Suggestive RF include >3.0 cm, mural nodules, symptoms concerning for malignancy, calcifications, + cytology on bx.

Answer 99

B Calculate FLR using CT measurements and calculated total liver volume on the basis of body surface area, which is independent of liver disease or tumor burden. Safe limits of resection are based on degree of underlying liver disease. >20% of preop liver volume in pts with N liver, >30% of preop liver volume in pts with early diseased liver and >40% in patients with well compensated cirrhosis Selective PV occlusion before operation may impeded tumor progression while allowing time for FLR to hypertrophy, potentially expanding the number of patients who may undergo resection. Although occlusion of the PB may be accomplished by ligation at open operation or by selected percutaneous venous embolization, of the 2 methods, embolization is preferable. Complications assoc with PVE occur in <5% and no specific embolization substance has emerged as superior.

Answer 100

A AIN is almost certainly the precursor in many, if not most, cases of anal SCC in HIV infected pts. Natural hx and management strategies are becoming more clear and common as more HIV pos patietns live with their chronic viral disease. HPV is understood to be carcinogenic in this area, as with cervical cancers in women. Pathology of SCC of the genital and anal regions is very similar. This disease may be largely preventable for men or women at risk, especially those who will have multiple partners in their lifetime with vaccinations. Antiviral regiments for HIV infections have not decr the rate of finding this disease, although active surveillance strategies may be uncovering more disease than known prev. AIN, which is essentially an in situ diseaase, is rarely fatal, even when it progresses to invasive anal cancer When suspected, thorough EUA is warranted to determine the extent of disease with lesion directed bx. Anal pap smears are non specific for invasive disease and do not help manage patients with known AIN. Close follow up is best strategy, Bx of ulcerated or concerning lesions but not try to eradicate a chronic viral infection with radical extirpation

Answer 101

B Demographics of anal SCC are evolving with emergence of high risk group of patients: HIV + male homosexuals prone to develop AIN that rapidly progress toward invasive anal SCC. Caused by oncogenic HPV. Neoadjuvant chemoradiation using 5-FU and mitomycin C before APR, several key points regarding tx have been established: 1) Anal SCC is a radiosensitive tumor, 2) Most anal cancers are cured with chemorads, 3) Surgical excsion is restricted to pts who fail to respond or who experience anal cancer recurrence after chemorads HIV positive pts with evidence of persistent HPV infection within the anal canal progress more quickly toward invasive carcinoma adn are on avg 15 yrs younger that the time of initial dx. Overall survival of HIV postiive pts with anal SCC is similar to HIV neg patients, although major cause of death in such HIV pos patients is anal SCC. In addition, severe hematologic/skin toxicity can occur in up to 50% of HIV + pts tx with current chemo protocols. Local recurrence after chemorads remain a problme in HIV + pts, developing in 50% of patients at 5 yr follow up. Finally, HIV + pts who do not respond to chemorads adn require operative tx have assoc higher rate of noncurative R1/R2 resections and perineal wound complications

Answer 102

D FNH 3% in adults. Found incidentall in young women (8:1 F:M). Asymp in 80% with no incr of spont hemorrhage. Mesenchymal biliary hamartoma is a rare benign lesion seen most often in children with a slight male predominance w/o an incr risk of bleeding. Present with hepatomegaly. Lesion may mimic radiographic appearance of met dx and may require bx. Cystadenoma is rare benign liver tumor that orginates from intrahepatic bile duct. May become symp by causing obstruction of bile duct or causing pain by capsular stretch. Although these tumors may degenerate to malignancy as cystadenocarcinoma, they carry no incr risk of rupture Adenoma is rare benign liver tumor typically seen in yojng women. Reports of hemorrhage range from 30-50% and may be sudden and life threatening. Hemangiomas are the most common benign liver lesion, with a 5-20% prevalence. Few hemangiomas are symptomatic, however when they are large (>4 cm) they may cause pain by capsular stretch but are not assoc with spontaneous rupture

Answer 103

C Barium enemas involve higher radiation doses and therefore, risk are comparable with CTs

Answer 104

B Majority of recurrences occur in first 3-5 years and involve liver and local recurrences.

Answer 105

C Includes Albumin, Bilirubin, INR, Ascites, and Encephalopathy

Answer 106

C Ideal tx in pt with cirrhosis an an HCC within Milan criteria (single < 5 cm or <3 tumors <3 cm), who is not a candidate for resection is liver transplant. In pts with advanced liver disease, overall survival with liver transplant is better than resection Tumor <2 cm in diameter who are not resection or transplant candidates, ethanol ablation or RFA have equivalent outcomes but ethanol approach requires more tx sessions bc the necrotic effect ablation is not as predictable as with RFA. Tumors > 2 cm, the efficacy of RFA is better than ethanol. Some data show equivalent outcomes with HCC <2cm tx either with resection or RFA. Other studies show that resection is superior to RFA. This finding remains controversial and resection continues to be the recommended tx in pts who are candidates for resection. For HCC at least 2-3 cm, RFA is inferior to resection. Tx of HCC by TACE postively affects survival compared with best supportive therpay and is a good choice for patients with tumors who cannot be treated for curative intent by resection, transplant or ablation. Radioembolization, the hepatic intra-arterial injeciton of yttrium-90 bound microspheres, can induce tumor necrosis but there are no data comparing its efficacy to TACE

Answer 107

D Primary neuroendocrine tumor of the skin. Rare. Very high propensity for local recurrence and poor prognosis. Excision is primary tx, usually followed by radiation UV exposure may contribute to MCC b/c it is accepted that UV exposure leads to down regulation of immune response. This immune suppresion can lead to an increase in MCC HIgher incidence in immunocompromised pts, such as HIV and AIDS. Further supported by mean age of dx in transplant pts being decr by almost 20 yrs. Merkel cell polyomavirus is implicated in pathogenesis of MCC, which may account for its higher incidence in immunosuppressed pts. Incidence of MCC is not increased in pts exposure to radiation tx

Answer 108

B Rare. Slow growing, mesenchymal proliferations with benign histologic features and virtually no malignant potential. Arise sporadically or in assoc with FAP. FAP assoc desmoids tend to occur more commonly in intra-abdo site or the anterior abdo wall. Estrogens have been of interest in the pathogenesis of sporadic desmoids, b/c women have a higher incidence, particularly those of childbearing age. Sx is mainstay of therapy. High local recurrence rate, even after apparent complete sx resection; however there is no capacity for tumor mets. Variables assoc with local recurrence include site of tumor, b/c pts with tumor located at extremities or girdles having a higher recurrence rate, regardless of microscopic margin status. Effect of microscopic margin status is not clearly defined. Well documented cases of regssion, even after no tx, complicate tx dilemma and lead some to recommend expectant observation in some pts. No current role exists for chemoprophylaxis . If disease is considered unresectable, NSAIDs and antiestrogens are considered first line therapies with cytotoxic chemo or radiation usually administered for those who progress on a noncytotoxic regimen.

Answer 109

D Rare and aggressive. Radical resection, incl liver resection and lymphadenectomies are recommended for pts with resectable disease ad T1b (muscularis invasion) primary tumors. Pts with lymphadenectomyies that recover at least 3 LNs have sig improvement in long term survival compared with those who have fewer nodes recovered, particularly in T2/T3 tumors. Key determinant in outcome is ability to obtain a microscopically neg margin (R0). Role of adjuvant therapy in gb carcinoma is debated with chemo and radiation being advocated as adjuvant tx b/c of high 5 yr recurrence in majority of pts with advanced dz.

Answer 110

E Prevalence of panc neuroendocrine tumors has incr, perhaps b/c of improvements in dx. Present challenges regarding prognosis b/c of risk of tumor recurrence and mortality correlates poorly with the usual gross and microscopic markers of malignant tumor behavior. In study of pts with panc neuroendocrine tumors who underwent curative resection, tumor size > 5 cm and LN mets were assoc with worse disease free survival. Among pts with advanced tumors not amenable to curative resection, the tyrosine kinase inhibitor sunitinib improves progression free and overall survival. A majority of pts w/neuroendocrine tumors develop liver mets. Resections of these met tumors offer a survival advantage over chemoembolization. Controversy surrounds an association between neuroendocrine tumor fcn and prognosis, with the majority of studies showing no association.

Answer 111

C In the United States, nonparasitic splenic cysts may be posttraumatic or primary (figure 1). Rupture of splenic cysts either spontaneously or posttraumatically is rare. Studies suggest that fewer than 60% of posttraumatic cysts are symptomatic. Few data support the use of cyst size as an indication for splenectomies in asymptomatic patients. Postaspiration cyst and symptom recurrence are very common; however, symptomatic relief with aspiration can suggest a benefit of operative management of splenic cysts. Because of the benign nature of the majority of splenic cysts, partial splenectomies or partial cystectomies (unroofing) are reported in most patients.

Answer 112

D Per-oral endoscopic myotomy (POEM) divides only the circular muscle fibers of the lower esophagus and stomach. It is proposed that this incomplete ablation of the lower esophageal complex compared with the Heller procedure lowers the 20–100% incidence of gastroesophageal reflux that accompanies the Heller procedure and necessitates a gastroesophageal fundoplication in combination with a full-thickness myotomy. A 2014 study compared consecutive groups of patients treated with the 2 procedures. Technical complication rates were similar with the 2 procedures. Successful treatment of dysphagia with POEM, and rarely symptomatic gastroesophageal reflux, was comparable to the results with Heller myotomy and partial gastric fundoplication. The purpose of adding partial gastroesophageal fundoplication to a Heller myotomy (circular and longitudinal muscle layers) is to prevent gastroesophageal reflux after this procedure

Answer 113

B Seventy-two percent of patients who chose “watchful waiting” in the British trial went on to operative management over a median of 7.5 years, and 68% of patients who chose “watchful waiting” in the US trial went on to operative management over a median of 10 years. Among patients who were 65 years of age or older, the operative conversion rate was 79% in the US study. The main reason for choosing operations was pain. Both studies demonstrated less than 3% rates of hernia complications (bowel obstruction or strangulation of hernia contents) during periods of “watchful waiting.”

Answer 114

D The majority of appendiceal carcinoid tumors are small, and they are discovered incidentally. Lymph node metastases from the tumors are predicted most accurately by size, with tumors less than 1 cm in diameter and confined to the appendix not associated with lymph node metastases and treated with appendectomy alone. Tumors greater than 2 cm in diameter are treated with right hemicolectomy. Controversy surrounds the management of patients with tumors 1–2 cm in diameter as well as carcinoids at the base of the appendix. The status of regional lymph nodes does not influence 10-year survival. Because the majority of tumors are less than 1 cm in diameter when they are discovered and unlikely to be associated with metastatic disease, the incidence of carcinoid syndrome is very rare in patients with appendiceal carcinoid tumors.

Answer 115

C This patient has evidence of infected pancreatic necrosis (figure 3). Up to 30% of patients develop infection after necrotizing pancreatitis, with presentation on average 3–4 weeks after the original management of pancreatitis. In this case, the extraluminal gas evident on CT imaging is suggestive of the diagnosis, even without culture results. Management of infectious complications after pancreatitis and pancreatic necrosis has evolved in recent years from mandated laparotomy and open necrosectomy. Recent reports demonstrate that percutaneous drainage may control sepsis and avoid surgery in more than 50% of patients; if the patient has ongoing sepsis uncontrolled by percutaneous drainage, surgical intervention should be entertained. In those cases, the percutaneous drain can serve as a “road map” to direct a minimally invasive approach, such as the step-up approach or video-assisted retroperitoneal debridement. Minimally invasive surgical approaches have lower morbidity (e.g., multiple organ failure, incisional hernia, new onset diabetes) and mortality rates compared with open necrosectomy. Enteral nutrition tends to improve outcomes for pancreatitis, so indefinite bowel rest is not advocated. Antibiotics alone for a fluid collection of this size, particularly in a patient with sepsis, is not advocated. Distal feeding access may be desirable, particularly for those patients with a gastric ileus, but that would not be the first step in management.

Answer 116

A Gallstones and alcohol are the most common causes of acute pancreatitis. The presence of high serum lipase and typical abdominal pain suggests the diagnosis in the absence of a CT scan. The presence of gallstones by abdominal ultrasound suggests the etiology, which can be further supported by the presence of a dilated common bile duct and the finding of elevated serum transaminases. The vast majority of stones pass spontaneously within 48 hours of presentation. Mild cases can be treated with hospital admission, fluid resuscitation, and pain control. In patients with more severe disease, cholangitis, persistent hyperbilirubinemia, clinical deterioration, or detection of a persistently impacted common bile duct stone, endoscopic retrograde cholangiopancreatogram (ERCP) is warranted within 24–48 hours. In patients with resolving symptoms of gallstone pancreatitis, cholecystectomy is indicated to remove the source of stones and prevent recurrence. Delayed cholecystectomy is associated with a high rate of recurrence of pancreatitis. A randomized trial demonstrated that early laparoscopic cholecystectomy is associated with a shorter overall length of hospital stay without increasing operative complications or conversion rates, compared with delayed cholecystectomy. Magnetic resonance cholangiopancreatogram (MRCP) does not offer therapeutic options and is reserved for cases that have an equivocal diagnosis or anatomy.

Answer 117

C This individual is in a high-risk group for hepatocellular carcinoma (HCC), and this presentation is likely a ruptured HCC. A biopsy is unnecessary and unsafe at this point. The immediate goal is control of the bleeding. The diagnosis may be confirmed based on the result of the recommended therapeutic arteriography. The patient’s abnormal hemodynamics and active bleeding warrant urgent intervention. HCCs have a rich arterial supply, and embolization is the preferred first intervention in the setting of acute rupture. The expected success rate would be better than 80%. The bleeding is clearly arterial, as evidenced by the blush seen on CT scan (figure 2), so transjugular intrahepatic portosystemic shunt (TIPS) would not be indicated. TIPS would be considered in the setting of bleeding from esophageal varices refractory to endoscopic intervention. Surgical approaches to this presentation—resection or packing—carry a significant risk of morbidity and mortality in the acute setting in patients with chronic liver disease and should be reserved for patients failing embolization.

Answer 118

D In this patient, there are several contraindications to liver-directed therapy. The short disease-free interval and presentation with multiple lesions suggests poor tumor biology, or inadequate initial staging, or both. Metastatic esophageal adenocarcinoma is rarely confined to the liver; therefore, systemic therapy is indicated. There is no evidence that resection has added benefit over systemic chemotherapy. Noncolorectal, nonneuroendocrine cancers metastatic to the liver are a heterogeneous group of diagnoses with highly variable biology. Few tumor types, other than colorectal carcinoma, are known to metastasize to the liver in a manner amenable to curative intent intervention. Most studies show no benefit of resection or ablation of liver metastases in the treatment of gastrointestinal malignancies. Radiofrequency ablation and other percutaneous thermal ablation techniques enjoyed popularity in the past decade due to ease of delivery and generally favorable safety profiles. The limitations of the technology include tumor number and size. The ability to reliably and safely destroy tumors larger than 3 cm is in question, with local failure rates in tumors larger than 5 cm being greater than 30%. External beam radiation is an attractive option given recent advancements in tumor localization and delivery. The literature supports a role in palliation of symptomatic lesions but not in curative intent treatment. Likewise, transarterial chemoembolization has a theoretical role in palliation of vascular lesions but is not a standard for any broad set of diagnoses.

Answer 119

B The initial diagnosis and classification of nonbleeding esophageal varices is usually made on esophagogastroduodenoscopy. In most centers, varices are classified by a semiquantitative morphological assessment into 3 sizes or grades: - Small (grade I), generally defined as minimally elevated veins above the esophageal mucosal surface normal in color, straight, and compressible. - Medium (grade II), medium varices defined as tortuous veins occupying less than one-third of the esophageal lumen, with or without red wheals, and noncompressible. - Large (grade III) defined as those occupying more than one-third of the esophageal lumen, with or without red wheals, and noncompressible. Nonselective beta-adrenergic blockers are the foundation of therapy for primary prophylaxis for preventing variceal bleeding. Patients with cirrhosis and varices that have not bled should be started on primary prophylaxis. A meta-analysis of 11 trials (1189 patients) evaluated nonselective beta-blockers (e.g., propranolol, nadolol) versus nonactive treatment or placebo in preventing first variceal hemorrhage. In patients with large- or medium-sized varices, risk of first variceal bleeding was significantly reduced by beta-blockers (30% in controls vs. 14% in patients treated with beta-blockers). One bleeding episode was avoided for every 10 patients treated. Two invasive endoscopic approaches to manage esophageal varices are available: sclerotherapy and banding. Endoscopic sclerotherapy is associated with a higher risk of side effects compared with variceal band ligation (VBL). Therefore, variceal band ligation is the preferred method for endoscopic prophylaxis of variceal bleeding. A meta-analysis of 5 randomized clinical trials comparing VBL with no treatment showed a decreased risk of first variceal bleeding and a lower mortality rate in the VBL group. Spironolactone in combination with beta-blockade shows no benefit over beta-blockade alone for primary prophylaxis of variceal bleeding. Nonselective beta-blockers or variceal band ligation may be an appropriate first-line choice for primary prophylaxis of variceal bleeding. However, the combination of both therapies is not more effective and is associated with increased side effects.

Answer 120

E Gallbladder polyps are identified in 1.5–6.9% of the population. They can be classified as “pseudotumors” (cholesterol polyps, adenomyomas, or inflammatory polyps), epithelial (adenomas), mesenchymal (leiomyomas), and malignancies (adenocarcinomas). The main concern when a polyp is identified is whether it is malignant. Single polyps are more likely to be malignant than multiple polyps. The feature most predictive of malignancy is the size of the polyp. A polyp larger than 1 cm in size has a risk of malignancy of 43–77%, whereas polyps larger than 2 cm are nearly always malignant. Age also needs to be considered; patients older than 50–60 years have a higher risk of malignancy. Finally, the presence of gallstones along with polyps or a diagnosis of sclerosing cholangitis and polyps increases the likelihood of malignancy. With the knowledge of these risk factors, a care plan algorithm can be designed. In a patient with true biliary symptoms, cholecystectomy is indicated based on the symptoms. The presence of polyps does not influence that decision. In patients with no symptoms and polyps 5 mm or smaller, a follow-up ultrasound in 6–12 months is indicated. If the polyps have not increased in size, no further imaging is needed. Polyps 6–9 mm in size can be followed with ultrasound. Typically, a follow-up study is obtained at 6 months and 1 year and then yearly thereafter if polyp size is stable. If the polyps decrease in size, no further imaging is needed. If they increase in size, a cholecystectomy is indicated. An exception could be a patient over the age of 50 with a single polyp larger than 5 mm. In a patient older than 50, cholecystectomy is indicated. All polyps 10 mm or greater in size require surgery. CT scanning should be considered in patients with polyps greater than 10 mm and age younger than 60 and in all patients with polyps greater than 20 mm to evaluate for invasive cancer. The role of endoscopic ultrasound in the management of gallbladder polyps is not well defined. Studies show it can be used to predict pathology at the time of cholecystectomy in 97% of patients. However, it is more invasive and expensive, and it requires endoscopists who have advanced endoscopic ultrasound training. Thus, although it may be useful in evaluating and staging larger polyps, it may not be the most cost-effective way to follow patients with smaller polyps. Open, nonradical cholecystectomy with lymph node sampling is not a procedure used for benign or malignant gallbladder pathology.

Answer 121

C Splenic abscesses are rare, but if not treated appropriately, they have a high mortality rate. The most common etiology is hematogenous spread, such as from infective endocarditis. Splenic trauma is another common etiology, as is splenic infarction. Up to 50% of these infections are polymicrobial. For this reason, empiric broad-spectrum antibiotics should be initiated as soon as the diagnosis is made. Primary fungal splenic abscesses are rare and antifungal therapy would not be initiated as part of empiric therapy. Antibiotics alone are not considered definitive treatment. Percutaneous drainage is now the procedure of choice for splenic abscess. Aspiration allows for culture-directed antibiotics in addition to preserving the spleen. Contraindications to percutaneous drainage include multiple abscesses and cysts that have features that make a diagnosis of Echinococcus more likely, such as a calcified cyst wall and the presence of other cysts in the abdominal cavity, particularly in a patient from the Mediterranean basin or Eastern Europe. Additionally, patients who are coagulopathic or those without safe percutaneous access to the abscess are not candidates for percutaneous drainage. Splenectomy is reserved for patients who are not candidates for or who have failed percutaneous drainage. There is no indication for the use of splenic embolization in splenic abscess, and it is one of the etiologies of splenic abscess.

Answer 122

D Pain is to be expected after any operation. It is important to recognize when pain has transitioned from acute to chronic. For an inguinal hernia repair, pain that exists beyond 3–6 months, which would be expected for the normal postoperative inflammatory response, is defined as chronic pain. It is estimated that 10–12% of patients will suffer chronic pain after inguinal herniorrhaphy (CPIH) and that 0.5–6% of patients will have pain that affects their daily life or employment. Evaluation of CPIH requires the surgeon to know the different types of pain that patients experience. Nociceptive pain is acute pain associated with acute stimulation or damage to sensory nerves. Touching a hot stove or a pain associated with a surgical incision are common causes. This type of pain often transitions to inflammatory nociceptive pain, in which inflammation leads to stimulation of the sensory nerves and the sensation of pain. An example would be pain that persists after spraining an ankle. These 2 types of pain represent the normal response to surgical injury. Etiologies of chronic pain can be simple to complex. Inflammatory pain can persist. This can occur if there is ongoing inflammation of the tissue and or a nerve in the region. Nerves injured at the time of surgery can form a neuroma that is hypersensitive. Ongoing pain stimuli can lead to a peripheral neuropathy, where there is peripheral amplification of normal nociceptive signals. Ongoing pain stimuli can lead to a central neuropathy where spinal cord neurons send increased pain signals to the brain. This is seen in allodynia (normal stimulus leads to the sensation of pain) and hyperalgesia (amplified response to a painful stimulus). For CPIH, it is important to differentiate hernia recurrence, direct nerve injury associated pain, chronic inflammatory pain, and neuropathic pain. The first 3 have surgical options, whereas a pain management specialist best treats the fourth. The pain associated with hernia recurrence is typical of an inguinal hernia. If physical exam is negative, an ultrasound exam done with the patient standing and performing a Valsalva maneuver can help to identify an occult recurrence. If the patient seems to be describing a recurrence, and evaluation is negative, diagnostic laparoscopy can be performed. Treatment is repair of the hernia. Direct nerve injury can lead to neuroma formation. Stimulation of the neuroma will cause an electric shock type pain. In the groin, the ilioinguinal, iliohypogastric, and genitofemoral nerves are all susceptible to injury. Because of the overlapping areas these nerves supply sensation to, any history of this type of pain or physical exam that elicits this type of pain (Tinel sign) should lead to nerve injury as the cause of CPIH. Nerve blocks can be attempted to confirm the diagnosis, but failure of the block could be based more on injection technique than wrong diagnosis. For this reason, with this type of pain, the surgeon can make a direct recommendation for triple neurectomy for treatment. Chronic inflammatory pain can occur due to the mesh, inciting chronic inflammation. Additionally, the mesh can contract, forming a “meshoma,” which can lead to chronic tissue inflammation and irritation. This pain typically remains in the groin and can be worse with movement. There is usually pain on palpation of the inguinal floor, but no electric shock type pain. Treatment can be initiated with anti-inflammatory agents, including steroids, in severe cases. If the mesh is stiff on exam, physical therapy, including scar release, can be attempted. If these fail, then mesh excision is considered. The most difficult diagnosis is that of chronic neuropathic pain. On exam, the physician will find a severe reaction to normal stimuli or to minimally painful stimuli. Pain will not be localized to the groin and may be described as the entire lower abdomen. Investigation for hernia recurrence is important. If a recurrent hernia is not identified, these patients are best treated by a pain specialist.

Answer 123

D Pain in the inguinal region without evidence of hernia is known by many names. Sports hernia and athletic pubalgia are used interchangeably in the literature, even though they are different entities. The term pubic inguinal pain syndrome (PIPS) is now used to describe the various forms of non-hernia-associated inguinal pain. Most important in any discussion of PIPS is to ensure that the patient does not have an inguinal or femoral hernia. This is done by exam and, if negative, a standing Valsalva ultrasound (dynamic ultrasound) of the groin. If a hernia is not identified with either, then PIPS should be considered. PIPS has 2 main etiologies. The first is weakness or laxity of the inguinal floor. This is the classic “sports hernia.” Patients will describe more classic hernia symptoms and on exam, with palpation of the inguinal floor, pain is reproduced. Dynamic ultrasound can show weakness and bulging of the floor. Surgical reinforcement of the inguinal floor is the treatment of choice. The second etiology is inflammation and injury at the pubic tubercle and the associated musculotendinous insertions. Patients describe pain in the proximal medial thigh, below the scrotum, in the lower abdomen, and at the pubic bone. On physical exam, there is tenderness to palpation of the pubic tubercle and there may be tenderness along the thigh adductor tendons, the lower rectus muscle, or the medial aspect of the conjoined tendon. Diagnosis can be confirmed with MRI scanning, which will demonstrate inflammation of these areas. The etiology of these findings is thought to be muscular imbalances of the abdomen, pelvis, and proximal lower extremity. For this reason, physical therapy is the initial treatment of choice. If physical therapy fails, surgery to off-load tension on the pubic tubercle in addition to adductor tenotomy is indicated. Steroid and platelet-rich protein injections are used to treat osteitis pubis and would not be indicated for PIPS. If MRI identified a pelvic stress fracture, limitation of weight bearing would be considered. It is not used for PIPS.

Answer 124

C This patient presents a picture of cholangitis without evidence of the distal bile duct obstruction that would be expected with choledocholithiasis, a stricture complicating pancreatitis, or obstructing pancreatic/common duct tumor. The incongruity of history/physical and laboratory values should prompt further investigation before considering operative intervention. The degree of hyperbilirubinemia and elevated alkaline phosphatase do not support a diagnosis of acalculous cholecystitis. Because of its high sensitivity and specificity, noninvasive magnetic resonance cholangiopancreatography (MRCP) has largely replaced endoscopic retrograde cholangiopancreatography (ERCP) as the initial diagnostic test of choice. The MRCP images for this case show the classic “bead-on-a-string” appearance of sclerosing cholangitis (figure 2). Although placement of a stent might be useful for biliary decompression in the face of a dominant extrahepatic stricture, significant clinical improvement is unlikely in the presence of intrahepatic strictures. Because this patient may ultimately be considered for liver transplant, cholecystostomy drainage and a prolonged course of antibiotics is the most appropriate initial management for this patient. Primary sclerosing cholangitis is the classic hepatobiliary manifestation of inflammatory bowel disease, leading to cirrhosis and end-stage liver disease caused by chronic and progressive biliary strictures. Disease with no known precipitant is deemed primary sclerosing cholangitis, whereas a preceding identifiable biliary injury is designated secondary disease. Autoimmune diseases, including IgG4-associated autoimmune pancreatitis, ischemia, toxins, and inherited disorders, mimic the historical and radiologic features shown in the MRCP images. If confirmatory, a trial of corticosteroid immunosuppression is appropriate, and, in the absence of hepatocellular carcinoma, suitable patients may be considered for liver transplantation. Although cancer antigen 19-9 (CA 19-9) is an indicator of pancreatic carcinoma, it has poor sensitivity for early-stage cholangiocarcinoma. Because increased CA 19-9 concentrations may result from cholangitis alone, routine measurement in this setting is less valuable. Diagnosis of small-duct disease necessitates liver biopsy when a potential overlap with autoimmune hepatitis is suspected (10% of patients).

Answer 125

E Portal vein thrombosis (PVT) is a complication of cirrhosis commonly identified on imaging of patients with advanced liver disease and is associated with portal hypertension and hypersplenism. Chronic partial PVT may be asymptomatic, whereas acute complete obstruction may induce intestinal congestion with severe continuous or colicky abdominal pain and occasionally nonbloody diarrhea. Although PVT and its attendant portal hypertension pose a significant risk of variceal bleeding, a treatment algorithm combining anticoagulation and transjugular intrahepatic portosystemic shunting (TIPS) offers the best chance for restoring portal flow, reducing portal pressures, reducing thrombosis extension, and reducing the risk of intestinal infarction. Although appropriate for management of bleeding gastric varices due to splenic vein thrombosis, splenectomy decreases portal vein flow, thus increasing the risk of PVT. Splenorenal shunt, an option for management of bleeding varices, also decreases portal blood flow. PVT alone is not an indication for liver transplantation nor is it necessarily a contraindication. Its presence, however, is an independent risk factor for recurrent PVT after transplant and decreased perioperative survival. Complete or partial recanalization is associated with better survival rates and, therefore, anticoagulation is recommended in all patients with PVT.

Answer 126

D This patient’s workup was initiated by a concern for biliary colic. The ultrasound did not show cholelithiasis. Her laboratory picture of normal bilirubin and transaminase values with a marked elevation in alkaline phosphatase supports further imaging of the biliary tree. In this case, the magnetic resonance cholangiopancreatography (MRCP) shows a type I choledochocyst (figure 2). There is no evidence for distal or common duct obstruction warranting endoscopic retrograde cholangiopancreatography (ERCP) with stent or cholecystectomy with common duct exploration. A pancreaticoduodenectomy or Whipple procedure is generally reserved for a distal bile duct or pancreatic head malignancy. In this case, cholecystectomy with bile duct excision and Roux-en-Y hepaticojejunostomy is the procedure of choice. Choledochocysts are single or multiple dilations of the intrahepatic or extrahepatic biliary tree (figure 3). The classic triad of jaundice, right upper quadrant pain, and an abdominal mass is less common in adults than in children. Untreated, patients are at risk of developing recurrent cholangitis, liver abscesses, and cholangiocarcinoma. Those confined to the common bile duct, as in this patient, are well managed by cholecystectomy with complete cyst excision to include any abnormal common duct from the hepatic plate to the intrapancreatic portion of the duct for fusiform dilations and hepaticoenterostomy reconstruction. The hepaticoenterostomy can be performed as a hepaticoduodenostomy or a Roux-en-Y hepaticojejunostomy. The latter approach is preferred, because it excises all potentially premalignant cyst tissue and separates the biliary tree from the pancreatic duct, eliminating any mixture of pancreatic and biliary secretions that may contribute to disease pathogenesis. Hepaticoduodenostomy carries the risk of bilious gastric reflux, gastritis, and esophagitis. Overall complications are substantially lower with Roux-en-Y reconstruction (7%) compared with hepaticoduodenostomy (42%). If the cyst cannot be completely excised, stripping or ablation of the mucosa is recommended and the patient should be followed with regular ultrasound surveillance for evidence of malignancy development.

Answer 127

C Rectus sheath hematoma (RSH) is a condition characterized by abdominal pain and an abdominal wall mass. Fothergill sign is an abdominal wall mass that does not cross the midline and remains present with contraction of the abdominal wall muscles. It is useful to differentiate between a mass arising in the rectus muscle and intra-abdominal masses. This sign would be positive with RSH. Important risk factors for RSH include female sex, older age, anticoagulation therapy, and cough or other abdominal trauma. A high index of suspicion in the appropriate clinical setting can lead to rapid diagnosis via CT scan (figure 1) of the abdomen and pelvis, which is the diagnostic modality of choice for RSH and is more accurate than ultrasonography for this clinical entity. Most patients are successfully treated with symptom management. Anticoagulation should be reversed, if at all possible. There is no indication for antimicrobial treatment. Criteria for blood transfusion do not change with RSH, and few patients will require this. Mesenteric angiography would be appropriate in the setting of mesenteric ischemia, but the presentation would not be consistent with this diagnosis. Angiography might be needed if bleeding does not stop with reversal of anticoagulation. The need for operative intervention is even rarer than angiographic intervention, and typically arises when the patient is hemodynamically abnormal and other therapies have failed, or if the hematoma becomes secondarily infected and requires drainage

Answer 128

E Spontaneous bacterial peritonitis (SBP) is a bacterial infection of ascitic fluid without an intra-abdominal source of infection. SBP is associated with underlying conditions such as cirrhosis, nephrotic syndrome, and congestive heart failure. The patient will have abdominal pain, fever, leukocytosis, and an ascitic fluid sample demonstrating more than 250 neutrophils/mm3. Broad-spectrum antibiotics, typically a third-generation cephalosporin, are started immediately. Gram-positive and anaerobic organisms rarely cause SBP in cirrhotic patients making vancomycin or metronidazole inappropriate. Because the patient is not bleeding, neither fresh frozen plasma nor cryoprecipitate is necessary.

Answer 129

B Laparoscopic cholecystectomy is associated with a 0.4% incidence of bile duct injury. Errors in identification are the most common cause of bile duct injuries during laparoscopic cholecystectomy. The “critical view of safety” is advocated as a means of ensuring the cystic duct and artery are clearly identified and that no other structures are adherent to or mistaken for these structures before dividing them. The essential elements of this critical view are to visualize 2 and only 2 tubular structures entering the neck of the gallbladder with a view of the liver and cystic plate behind these cystic structures. Although intraoperative cholangiography can be complementary to the critical view of safety, it is not required. The cystic duct–common bile duct junction should not be routinely dissected, because this maneuver can actually increase the risk of a bile duct injury. At times, a top-down mobilization of the gallbladder may be necessary, but this is not part of or required for the critical view of safety. Visualizing 2 tubular structures in the triangle of Calot alone does not constitute this critical view.

Answer 130

A This patient is most likely bleeding from her peristomal varices given the negative upper endoscopy. The patient should be aggressively resuscitated with blood products, and any underlying coagulopathy should be corrected. A temporizing measure to consider would be to apply traction to a balloon-tipped catheter inserted into her ileostomy to temporarily control the bleeding. Although endoscopic management is often a first-line therapy in esophageal variceal bleeding, enteroscopy through the stoma is not likely to be effective in managing bleeding from peristomal varices, because they arise at the mucocutaneous junction. If transjugular intrahepatic portosystemic shunt (TIPS) is available, this intervention will significantly reduce the risk of current and future bleeding from peristomal varices. Operative intervention with portacaval shunt carries a significantly higher mortality in this case. Re-siting the ileostomy with or without ileum resection can be considered but should be performed only if TIPS is not available or other factors indicate a need for a new ileostomy site. Nonselective beta-blockers are useful in preventing initial variceal bleeds but are not indicated for a patient who is actively bleeding and in hemorrhagic shock.

Answer 131

A Echinococcus is endemic in much of the underdeveloped world, including Afghanistan. Four different species of this tapeworm infect humans, with Echinococcus granulosis being the most common. The x-ray and CT scan demonstrate classic findings of a calcified cystic wall in the lungs and liver (figure 4). Amoebic cysts, polycystic disease, and cystadenomas do not typically have calcified walls. Retained fragments or foreign bodies would have more beam-hardening artifact scatter around the radiodense structures. This patient underwent successful resection of her multifocal echinococcal disease in a staged fashion, starting with a left lower lobectomy, followed by a nonanatomic resection of her right upper lobe and excision of her hepatic cysts (video 1). During each procedure, the operative site was surrounded with laparotomy pads soaked in hypertonic saline, which is toxic to the parasite, and great care was taken during the cyst excision to avoid spilling the cyst contents. Spillage of cyst contents is associated with significant morbidity and mortality.

Answer 132

C Fatigue, weight loss, and pruritus are the classic presenting symptoms of primary sclerosing cholangitis (PSC). A history of ulcerative colitis, which is present in 75–80% of patients with PSC, strongly suggests the diagnosis. PSC has a slight male predilection and can involve both intra- and extrahepatic ducts. Confirmation of the diagnosis is by cholangiography, preferably magnetic resonance cholangiography, which has the advantage of being noninvasive and cost-effective and has a sensitivity of better than 90%. Endoscopic retrograde cholangiography, which has a sensitivity approaching 100%, is currently reserved for equivocal finding by magnetic resonance cholangiography. Cholescintigraphy (HIDA scan) is not helpful in confirming the diagnosis, because this imaging modality lacks sufficient detail to show the classic “beads-on-a-string” anatomic configuration of the ducts. Percutaneous liver biopsy is not necessary for the diagnosis. Endoscopic or transabdominal ultrasound, while beneficial in the identification of choledocholithiasis or pancreatic pathology, is not recommended for suspected PSC, because it cannot evaluate the intrahepatic ductal system. The determination of serum antibodies (e.g., p-ANCA and ANA) is useful in suggesting autoimmune disorders but lacks the ability to differentiate the many autoimmune conditions, such as rheumatoid arthritis, Sjögren syndrome, and celiac disease. The elevation of serum alkaline phosphatase is the primary laboratory abnormality in PSC patients. Most patients present with normal bilirubin levels; the marked elevation of bilirubin in this case is suggestive of advanced disease or malignancy. Patients with a history of ulcerative colitis have an increased risk of cholangiocarcinoma, and those with a history of “pouchitis” have an even greater risk. For patients with PSC, intact colons, and ulcerative colitis, the risk of colorectal cancer, preferentially the right colon, is increased by some reports 160-fold over normal individuals. The relationship between PSC and ulcerative colitis remains obscure, and theories include genetic (variants in HLA genes), geographical (prevalence in the United States and European countries 100-times greater than in Asia), bacterial toxins (colonic bacterial overgrowth with exaggerated immune response), and environmental factors (tobacco smoke and environmental toxins), or combinations of these. Endoscopic stenting of the bile ducts, preferentially with self-expanding metallic stents, has some role in palliation in PSC. Some studies suggest that stenting of just a few of the stenotic ducts provides symptomatic relief in most cases. Sphincterotomy and cholecystectomy have no therapeutic or even palliative benefit. Corticosteroids and immunosuppressive agents are not of any value, either in providing symptomatic relief or in delaying progression of the disease. However, in patients with symptoms overlapping autoimmune hepatitis, corticosteroids may have a role. The only effective therapy for end-stage PSC is liver transplantation. In fact, PSC is the most common indication for liver transplantation in Scandinavia and the fifth most common indication in the United States. Unfortunately, transplanted livers have a 20% chance of developing a recurrence of PSC, and this may ultimately lead to graft rejection.

Answer 133

A Chronic pain after inguinal hernia repair is reported to occur in 5–30% of patients. Although there is overlap in the different entrapment syndromes, detailed anatomic knowledge of the innervation is critical to avoid entrapment and assist in diagnosis and management of postherniorrhaphy neuralgia when it occurs. The ilioinguinal nerve and iliohypogastric nerves have similar anatomic origins, courses, and sensory innervation. They provide sensory innervation to the proximal and medial thigh, base of the penis, and upper scrotum. The lateral femoral cutaneous nerve should be well away from the operative field. Its sensory innervation is to the anterolateral thigh. The genital branch of the genitofemoral nerve provides sensation to the scrotum. The femoral branch of the genitofemoral nerve innervates the anterolateral thigh. The obturator nerve passes through the obturator canal well away from the operative field (figure 1).

Answer 134

B Idiopathic thrombocytopenic purpura (ITP) occurs when autoantibodies against platelet glycoprotein complexes result in varying degrees of thrombocytopenia. The spleen is the predominant site of antibody-induced platelet sequestration and destruction. Splenectomy is advocated in adults with thrombocytopenia from ITP with reported long-term remission rates of 66–85% compared with much lower remission rates reported from medical management (<30%). The benefits of laparoscopic splenectomy reinvigorated the interest in splenectomy as a treatment for ITP. Many studies examined factors that predict a sustained improvement in platelet counts after splenectomy. Although the degree of response to steroids and shorter duration of disease are positive predictors of response, the most consistent, independent predictor is younger age. There is no specific age cut off; the younger the patient is, the more likely the chance of complete remission. Lower platelet counts are a negative predictor. A few studies show that spleen size does not predict response. In general, patients with ITP have normal to slightly enlarged spleens. Splenomegaly is uncommon.

Answer 135

B Liver abscesses can be caused by fungus, bacteria, and amebae. Patients commonly present with constant, dull right upper quadrant abdominal pain, probably due to stretching of the liver capsule. Fever is common. Abscesses tend to occur in the right lobe, presumably due to the larger hepatic volume and predominant flow of blood from the superior mesenteric vein draining the gastrointestinal tract as opposed to the splenic vein. The presence of multiple abscesses suggests a bacterial or mixed source. The treatment of liver abscesses has changed with the emergence of medical technology, particularly imaging and image-guided percutaneous interventions. A century ago, patients with multiple hepatic abscesses had a nearly universal mortality. Abscesses not amenable to percutaneous drainage may be successfully treated with antibiotics alone. In this case, the 5-cm fluid collection in the right lobe would be accessible by percutaneous means. The enhancing rim suggests characteristics of a pyogenic abscess. The negative amoebic serology eliminates amebae as the cause. Percutaneous drainage, with or without a catheter placement, improves the likelihood of treatment success. Occasionally, repeated aspirations are needed and can still result in treatment success. The morbidity of surgical drainage or even hepatectomy precludes its use. In the Western world, bacterial hepatic abscess is most common. In developing countries, particularly southeast Asia and Africa, amebic infection is the most frequent cause. Amebic liver abscess is caused by the protozoa Entamoeba histolytica, and most can be treated with amebicidal drug therapy alone.

Answer 136

E To assist with risk stratification of surgical site events and operative decision making, the Ventral Hernia Working Group (VHWG) developed a 4-tiered grading system (figure 1). VHWG recommends the use of synthetic mesh for low-risk hernias (i.e., grade 1) and bioprosthesis for potentially contaminated and infected hernias (i.e., grades 3 and 4, respectively). Biologic meshes placed in between two layers of vascularized tissue allow rapid host cell and vascular infiltration, which is believed to help them resist infection more effectively than synthetic meshes. In addition, biologic implants have high salvage rates in the setting of infection and enteric contamination. In this patient with a recurrent incisional hernia and violation of the integrity of the small bowel (i.e., a VHWG grade 3 hernia), biologic mesh placement is the suggested therapy. Placement of synthetic mesh is not recommended. Polyester, polypropylene, and polytetrafluoroethylene are all permanent synthetic materials. Polyglactin is an absorbable synthetic material, which is prone to recurrent hernias.

Answer 137

C Inguinal herniorrhaphy is one of the most commonly performed surgical procedures today. Incidence of “groin hernias” is substantially higher in male patients (2–5% vs 0.3% in women). Although femoral hernias comprise only a small minority of groin hernias in men, they represent nearly one-third of the groin hernias in women. After open mesh repair, a “recurrence” in women is often seen in the femoral canal. The most likely explanation is that these are not recurrences but rather errors in diagnosis leading to the incorrect operation. A traditional, open, tension-free, mesh repair (Lichtenstein) will address both the direct and indirect defects but does not cover the femoral canal. Both McVay and open preperitoneal repairs will address the femoral canal, but these are less commonly performed than open Lichtenstein procedures. A laparoscopic, extraperitoneal herniorrhaphy allows for exploration and coverage of the entire myopectineal orifice, addressing both inguinal and femoral hernias. In women, laparoscopic preperitoneal repair is associated with a lower recurrence rate than open mesh repair.

Answer 138

E Management of asymptomatic or minimally symptomatic hernias is evolving as long-term randomized controlled study data for watchful waiting are reported. Since their original report in 2004 demonstrating safety of watchful waiting during short-term follow-up (median 3.2 years), Fitzgibbons et al. followed patients up to 11.5 years and found that the overall crossover rate to surgery is 68%. Men older than 65 are significantly more likely to crossover to surgery than are younger men (79% vs 62%). The most common reason for surgery was pain (54%). Only 2.4% of watchful waiting patients required emergency operation for complications such as strangulation or obstruction. The authors concluded that watchful waiting is therefore safe, regardless of the timing of onset of the hernia, presence of a bulge, or age of the patient, but most patients will experience a progression of symptoms and ultimately need surgical repair. A similar study in the United Kingdom found that 72% of the watchful waiting cohort came to operative therapy at 7.5 years of follow-up.

Answer 139

E Only 12% of patients with melanoma who had occult LSN positive were found to have additional positive LNs are completion lymphadenectomies

Answer 140

B Patient has early stage breast cancer (T1-2, clinically node neg) and is undergoing BCT Z011 study had similar patients which randomized pts who were found to have 1-2 positive SLNs to either no further axillary sx or ALND. Study showed no difference in 5 yr survival or DFS for the 2 groups Omission of ALND may be safe b/c these patients receive axillary radiation as standard adjuvant therapy after lumpectomy. Avoid overextending the results in patient who had mastectomy, who do no receive axillary radiation for early stage breast cancer, and patients tx with partial breast irradiation who do not receive any dose to the axilla. For at least 3 positive nodes on permanent pathology, further axillar tx should be considered. Study also excluded whole breast radiation in prone b/c those patients do not receive any radiation to the low axilla

Answer 141

E Breast cancer in BRCA1 patients are more likely to be "basal" type tumors (ER -, PR -, HER-2 -) . These triple neg breast cancer have a particularly worse outcome compared with other breast cancers. B/c BRCA-1 related cancers tend to occur in younger women, this greater tendency for such cancers to be basal type explains in part the long observed worse prognosis of breast cancer in younger women Conversely BRCA 2 mutation carrier tned to have similar histopathologic features as sporadic cancers. Accordingly, a meta analysis showed decreased OS for BRCA 1 assoc breast cancers vs no effect for BRCA 2 mutations on survival

Answer 142

C Freq downsizing of tumors seen with upfront chemo allows increase use of BCT, resulting in improved cosmesis. B/c tumor response can be directly monitored, neoadjuvant therapy provides an in vivo test of the tumor's sensitivity to treatment Significant improvement in DFS and OS. Trends in improved survival were seen in NSABP B 18 and B 27 for women younger than 50 years. Further 13-26% of patient who achieved complete pathologic response had improved survival compared with those who did not have a pathologic complete response. Seen more commonly in patients who have neg prognostic factors: <40 yrs old, high grade tumors, Her2 positive, and ER -] Most chemo drugs and regimens approved for post op can be used pre op (NSABP used doxorubicin, cyclophosphamide, and docetaxel).

Answer 143

E Isolated axillary adenopathy is a concerning physical finding requiring complete evaluation. Fortunately, it is assoc with malignancy in only a minority of cases. When subjected to bx, nonspecific inflammatory changes or findings consistent with granuloma are typically identified. Malignancy accounts for <25%, lymphoma accounting for 14% and metastatic carcinoma for 10% Work up: Complete H&P including breast exam and skin exam. If >35 yrs then mammogram. US is reliable for differentiating benign and malignant lymphadenopathy and useful in the management of patients with unilateral axillary adenopathy with otherwise N findings. US directed DNA should be considered for LNs with abN morphology. Asymp pts with normal appearing LNs on US are managed with a period of watchful waiting.

Answer 144

B Trastuzumab is highly effect for breast cancer patients with HER 2 neu amplified tumors; it reduced the risk of death by at least 39% in several prospective randomized trials.

Answer 145

C BSO decreases breast cancer risk by 50%. Bilat ppx mastectomy decreased breast cancer risk by 90-95% by removing the majority of the breast tissue. It does not completely eliminate breast cancer risk. Tamoxifen decreases breast cancer risk by 50% and is an effective chemoprovention agent. Annual MRI for screeing is recommended for women whose lifetime risk of breast cancer is 20-25% or higher. Anastrozole has not been evaluated for chemoprevention, and its use is limited to post menopausal patients with breast cancer

Answer 146

A Z011 evaluated women with T1 or T2 tumors who were clinically node negative at presentation undergoing BCS, who were found to have 1 or 2 positive SLNs and who were receiving whole breast radiation. Pts with at least 3 postive SLNs. with gross extranodal extension, receiving noeadjuvant therapy, undergoing mastectomy or not receiving whole breast radiation were not eligible. No difference in in-breast recurrence, axillary recurrence, 5 yr DFS or 5 yr OS between women undergoing ALND and those women who did not undergo ALND. Most women in the study were postmenopausal with low grade, ER +, and 96% received adjuvant systemic therapy. Women who meet Z11 criteria and have 1 or 2 positive SLNs now can be spared Ax dissection. Whole breast radiation is recommended for these patients and these data should not yet be extrapolated to pts undergoing partial breast radiation, no radiation, neoadj endocrine or chemo, mastectomy or 3 or more postive LNs ALND can be avoided for patients who meet all of the following criteria: - Breast conservation - Whole breast radiation (not partial breast radiation) - Clinical T1 or T2 and N0 - No neoadjuvant chemo - 1 or 2 postive SLNs

Answer 147

B Highest SLN identification rates and lowest false neg rates have been reported with the use of dual mapping agents: radioactive colloid and blue dye. LIfe threatening anaphylaxis have been reported in 1% of cases with use of isosulfan blue. It can also interfere with pulse oximetry, resulting in falsely lowered peripheral oxygen saturation readings. Subareolar injection of mapping agents results in the fastest drainage to the ipsilateral axillary LNs and can be used for many breast cancer cases; however for patients with recurrent breast cancer, peritumoral injection is recommended. Detection of lymphatic drainage to internal mammary LNs allows the option for resection; however, this finding remains controversial and for primary breast cancer, most surgeons do not resect internal mammary LNs as long as an axillary SLN is identified. SLN surgery is used in male breast cancer, multifocal breast cancer, multicentric breast cancer and patients after neoadj chemo with clinically neg nodes at presentation

Answer 148

E 7 prognostic factors for local recurrence: patient age, tumor size, tumor grade, margin status, LVI, chemo use and hormone therapy use Incr risk of local recurrence after breast conservation include those with a young age at dx (< 40 yrs). Young age is a poor prognostic factors for breast cancer. Incr age is assoc with decr risk of local recurrence independent of breast cancer subtype. Local recurrrence is higher among HER2 postive and triple neg. Lower recurrence in ER+ breast cancer.

Answer 149

E ALH is a factor for incr risk of breast ca development (4x). Not thought to be a precursor lesion to breast ca. # of foci correlates with risk--multifocal atypia have higher risk than single focus of atypia ALH on core needle bx--> consider surgical excision especially if pathologic-radiologic discordance or any residual imaging abN. Ax nodal staging not recommended. Chemoprevention with tamoxifen, raloxifene and exemestane is recomneded for consideration for women with atypia. Tamoxifen decr risk of breast cancer by 50% or more.

Answer 150

E Adj radiation decr local recurrence rates after lumpectomy for pts with invasive breast cancer and DCIS. Post mastectomy radiation is recommended for pts with invasive disease >5 cm, chest wall invasion, persistent positive margins, or postive LNs (clasically >4 LNs and increasingly also for 1-3 + LNs). Not recommended if invasive disease <5 cm, neg margins and neg LNs. SLNB for DCIS tx with BCS is not recommended. SLN sx for axillary staging should be used only for cases of DCIS that are > 5cm in size, palpable, assoc with microinvasion or tx with mastectomy. Adj therapy for DCIS consists of tamoxifen and is used to decr the risk of future breast cancer event, most commonly recurrence or new primary in the ipsilateral or contralateral breast. AIs have not been studied in women with DCIS. Women with DCIS tx with bilat mastectomy are not recommended to receive adjuvant endocrine therapy.

Answer 151

E Partial breast radiation delivers radiation to the lumpectomy bed and surrounding breast tissue. After lumpectomy, in breast recurrence can be classified as tumor bed recurrences (near lumpectomy cavity) and elsewhere recurrences. Majority after BCT and whole breast radiation are in the region of the tumor bed Partial breast radiation allows radiation to be delivered over a shorter time course. Suitable candidates are women > 45 y.o. with invasive ductal carcinoma, tumore < 3 cm, neg margins, node neg. Location within the breast is not a limiting factor regarding use of partial breast radiation.

Answer 152

E ACS recommends annual MRI screening for women with a lifetime risk of breast ca of at least 20-25%, known BRCA 1 or 2 mutation carriers, untested 1st degree relative of known BRCA 1 or 2 mutation carriers. Based on expert consensus opinion, annual MRI screening was recommended for patients with radiation to the chest between 10 and 30 yrs, Li Fraumeni syndrome or Cowden syndrome. Diagnostic MRI in patient with axillary mets thought to be of breast origin and mammogram and ultrasound do not identify the primary tumor. Useful to reconcile differences between clinical findings on exam and mammo or US. Response to neoadj chemo can be evaluated on MRI. MRi can be considered in women with dense breast tissue, invasive lobular cancer or women presenting with mammographically occult disease.

Answer 153

B Women identified to be at elevated risk of breast ca should be counseled regarding their risk reduction options. Chemoprevention with meds such as tamoxifen, raloxifene or ezemestane can decr risk of breast cancer development by 50%. BSO results in risk reduction of breast cancer by 50% and decreases risk of ovarian ca by 90%. In women with BRCA 1 or 2, bilat ppx mastectomy significantly reduces the risk of breast ca and BSO is assoc with a significant decr in ovarian cancer, risk of breast cancer, all cause mortality, breast cancer specific mortality, and ovarian cancer specific mortality. Cancer reducing benefits observed are the greatest when the procedures are performed before age 50

Answer 154

A LCIS is typically dx in women in their 40s, full decade earlier than most women with DCIS. LCIS is considered a risk indicator for the development of invasive breast cancer, rather than a precursor lesion. When LCIS is dx on sterotactic core bx, operative excisional bx is indicated to exclude an adjacent invasive breast cancer. Surgical excisional bx has a 20-30% incidence of a malignant lesion near LCIS. If invasive breast cancer is not identified on final pathology, patient is followed with annual mammo and physical exam. If needle localized excisional breast bx has LCIS at the margin, repeat excision is not indicated. PPX bilat mastectomy considered if strong fam hx or BRCA 1 or 2 mutation. Premenopausal considered at high risk of developing invasive breast cancer may be candidates for chemoprevention with tamoxifen, which can decrease risk by almost 50%. Must weigh risks and benefits of 5 yrs of tamoxifen therapy including thromboembolic disease and uterine malignancy. LCIS increases risk 3x for ipsilateral breast compared to contralateral.

Answer 155

B Recent studies sow that needle aspiration and ABX can be used as 1st line tx for simple breast abscesses. I&D reserved for pts who do not resolve with repeated aspirations. Placement of drain catheter is considered for abscesses > 5 cm. Fewer than 5% of pts with a breast abscess have an assoc malignancy. Pts should undergo repeat imaging ~6 wks after clinical resolution of the infection. If there is residual noninflammatory mass, a core bx should be performed to evaluate for malignancy. If cellulitis and assoc breast mass do not improve with abx, malignancy should be suspected and bx should be performed. Inflammatory cancer typically occurs at an older age and presents with erythema and edema of 1/3 of the breast or more. Although the dx of inflammatory breast cancer remains clinical, a punch bx of the skin showing invasion of dermal lymphatics can assist in confirming the dx

Answer 156

D Sterotactic bx is used for dx of nonpalpable masses or microcalcifications noted on mammo. If ADH is identified on pathologic review, excisional bx is indicated to exclude invasive carcinoma; an image guided core bx underestimates the presence of DCIS or invasive cancer in 10-20%. If, after excisional bx, there is no additional DCIS or invasive cancer that requires tx, patient may consider further chemoprevention with tamoxifen and will require annual mammography for screening.

Answer 157

A Mondor disease is a superficial thrombophlebitis of the subcutaneous veins. Most common site is anterolateral thoracoabdominal wall, including the breast, other sites include the antecubital fossa, penis and posterior cervical region. Painless, cord like induration. Cause unknown although most commonly assoc with trauma. Easily dx by physical exam. Occasionally, mammo and U/S may be used if there is suspicion of underlying breast pathology, but neither is routinely required. Bx, either punch or excisional is rarely indicated. Tx is reassurance b/c this is self limiting. More aggressive tx is required only for symptoms, which are generally focused on symptom relief

Answer 158

B Micromets as a cluster of cancer cells 0.2-2.0 mm in size. Isolated tumor cells <0.2 mm. Completion ALND is not required. Axillary radiotherapy is not required b/c risk of axillary recurrence is low. Local recurrence risk is not increased. No difference in survival.

Answer 159

D Even though the most common cause of a red breast is infection, it can represent an inflammatory breast cancer. Inflammatory breast cancer is not common, ~1-5% of all breast cancers. Dx with mammogram and U/S early, whether or not there is a palpable breast mass or axillary adenopathy. If there is a palpable mass on exam or a radiographic abN, an incisional bx of the mass with attached/involved skin should be performed. If U/S suggests an abscess, drainage should occur and the pt should be placed on abx. If no abcess is seen but skin erythema is subtle, a percutaneous core bx of the underlying lesion should be performed. 5 yr survival ~40%, 20-35% will have distant mets at the time of presentation, 60-85% will have nodal mets.

Answer 160

C Differentiating DCIS from invasive ductal cancer with core needle bx affects the extent of surgery. Routine SLNB in all patients with DCIS on core needle bx is not recommended due to low risk of axillary LN mets. However, CNB may underestimate the presence of invasion and a final pathologic dx of invasive cancer then necessitates reoperation to stage the axilla. ~20% pts dx with DCIS on CNB are upstages after surgical excision. Selective use of CNB in pts with DCIS on CNB is recommended based on predictors of an invasive component. Strong predictors include presence of a palpable mass, microinvasion, and lesion of at least 2 cm on imaging. Additional confirmed predictors include high nuclear grade and presence of comedonecrosis, which are assoc with invasive cancer in 28% and 44% of patients.

Answer 161

D Phyllodes tumors are fibroepithelial tumors of the breast. Represent 1% of all breast tumors and most commonly affect woman 35-55 yrs of age. Dx is challenging b/x the clinical presentation is similar to fibroadenoma. Overlying skin may be discolored with dilated veins but skin invasion and nipple retraction are rare. Axillary dissection is not indicated b/c of low incidence of LN involvement. Std tx of phyllodes is surgical excision with a clear margin, regardless of tumor grade. Mastectomy may be necessary for larger tumors if they occupt the majority of the breast, b/c breast conservation with an acceptable cosmetic result is unlikely to be achieved.

Answer 162

A Common and debilitating side effect of breast cancer tx. May occur after SLNB if SLN is located at the level of the axillary vein or combined with axillary radiotherapy. ~7% with SLNB. If tx conservatively in the earliest stages, complications may be diminished or reversed. Intensive therapy such as PT, manual drainage, or pneumatic pump, yield greater volume reduction than compression garments or limb elevation. Low level laser therapy increases rate of lymph vessel pumping and promotes lymph vessel regeneration, reduced pain and softens fibrous tissue and surgical scarring. Exercise has been shown to significantly reduce severity of symptoms. Wt loss is shown to reduce upper extremity edema. Some studies have initiated therapy as early as 48 hrs after sx.

Answer 163

E Determine if nipple d/c is unilateral or bilateral and whether fluid is grossly bloody or contains blood. Galactorrhea is used to describe milky d/c from both breasts Any discharge not considered to be galactorrhea is caused by a ductal condition such as ductal ectasia, fibrocystic breast changes, intraductal papilloma, intraductal carcinoma and invasive ductal carcinoma (usually papillary type). Duct ectasia is characterized by diln of the major ducts along with inflammation and fibrosis around the ducts. D/C is usually green or black and guiac neg. Sx therpay is not necessary in women with classive multiduct non blood black green d/c. If only 1 duct is involved, therapy is usually excision to help dx the etiology. Fibrocystic disease typically results in serous or light green multiduct d/c. Complain of cyclic breast pain and premenstrual breast lumpiness, and exam reveals a diffuse find nodularity. Mammo and US are confirmatory and show dense breast tissue with nodularity and microcyst formation Most common cause of bloody uniduct d/c is intraductal papilloma. D/C is usually spontaneous but can be elicited by palpation and comes from a single duct orifice. Mammo is typically neg and US may show a dilated duct with an intraluminal lesion. Most intraductal papillomas occur near the areolar edge and galactography is recommended to identify more peripheral lesions. Galactography involves cannulation of the duct orifice and injection of radiopaque dye; papillmas are seen as intraluminal filling defects. Tx is duct excision Intraductal and invasive ductal carcinoma are only rarely assoc with nipple d/c in the absence of an abN mammo or palpable mass. DCIS and papillary carcinoma cause most cancer associated nipple d/c. Occasionally, blood d/c is present in Paget's disease--a scaly, raw, vesicular or ulcerated lesion that beings on the nipple and spreads to the areola. LCIS and phyllodes are not assoc with nipple d/c

Answer 164

E Incr risk of breast and ovarian cancer in ppl who have inherited a deletrious mutation of BRCA1 or 2 genes. 10 fold relative risk of these cancers and incr risk more than any other factor. Female BRCA1 carriers have a lifetime risk of developing breast ca and ovarian/fallopian tube ca of approx 40-80% and 26-46%. For BRCA 2 mutations, risk is 30-60% and 10-20% Same specific BRCA mutation ends to be conserved w/in a given BRCA family, it is most efficient to test an affected patient (index relative) to determine whether a mutation exists and if a mutation is found, to then test other family members for the same mutation. Guidelines include 4 categories to determine which pts should be tested - Families with known BRCA 1/2 mutations - Personal hx of cancer and at least 1 of several other risk factors incl dx before age 45, ashkenazi jewish, and 2 breast cancers when the first was dx before age 50, people with certain cancers (male breast cancer, ovarian/fallopian tube cancers), and certain high risk family hx

Answer 165

B Breast MRI is appropriate in pts with nodal disease and occult primary cancers, those with multifocal or multicentric tumors and in assoc with conventional imaging for difficult primaries, such as invasive lobular carcinoma. Indicated to assess response to neoadj chemo in selected pts. Use is appropriate in addition to mammo for patients at very high risk for breast cancer, especially those with gene mutations such as BRCA 1 and 2 but it is not indicated to take the place of screening mammo In patients with clinically involved axillary nodes without any identifiable primary occurs in ~1% of all dx breast cancers. After mammo and U/S, MRI may identify primary tumors in up to 50% of these patients.

Answer 166

E Most common abscesses grow staph aureus and nearly 25% of abscesses occur in non lactating women. Breast abscesses <5cm can be tx successfully with U/S localization with repeated aspirations as required, leading to improved cosmesis at the drain site. US can distinguish abcesses from mastitis and US can facilitate complete drainage of abscesses including loculations. A thick abscess rind assoc with septa may indicate the need for surgical drainage in pts with larger abscesses

Answer 167

B A C Idiopathic granulomatous mastitis is a rare condition characterized histologically by noncaseating granulomas centered on lobules. Both can be associated with fistulas and abscesses. However, unlike periductal mastitis, idiopathic granulomatous mastitis is not assoc with smoking, occurs in younger women, and is often assoc with recent pregnancy. Patients with IGM are less likely to have used OCPs previously, to be white or respond to classic tx such as surgical drainage and abx. IGM is effectively tx with a variery of therapies including steroids, which may treat an underlying autoimmune casue. Aggressive surgical mgmt is rarely reqd. Regardless of tx, IGM often burns out spontaneously in 6-12 months. For both periductal mastitis and IGM, bx and close observation are critical to rule out inflammatory breast cancer

Answer 168

B B C DCIS is most commonly detected as suspicious microcalcs on routine screening mammo in an asymp woman. B/c most women with newly dx DCIS are eligible for BCT, a major decision is whether to add radiation after surgical excision. Addition of radiation after lumpectomy, reduces the risk of local recurrence by approx 50% for both overall local recurrence and subset of invasive local recurrence. Decision to excise isolated LCIS when found on core needle bx should depend on multiple factorsm including the imaging indication and findings, extent of LCIS on CNB and presence of concurrent atypical ductal hyperplasia on CNB. Proposed tx algorithm allows for close follow up for patients with calcs on routine mammo and isolated LCIS on CNB that meet the following criteria: 1) Normal risk pt undergoing routine screening mammo found to have calcs, 2) fewer than 4 foci of LCIS on CNB, 3) no other high risk lesion present. Staining for e cadherin can be used to differentiate ductal vs lobular carcinoma in situ b/c membranous staining is seen in most DCIS and neg in lobular neoplasia. Pts with hx of LCIS have a 4-10 x increased risk of subsequent invasive disease. Tamoxifen and raloxifene are equally effective in reducing this risk.

Answer 169

D A B SLNB is the preferred method of axillary staging for pts with breast cancer. 2 most common agents are isosulfan blue and technetium labeled sulfur colloid. Neither offers clear advantage. For most patients, they may be successfully used independently or in combo. Isosulfan blue is typically injected into breast 5-10 min before making the axillary incision. Technetium labeled sulfur colloid can be injected on the day before sx or as little as 20 min before sx. SLNB is the method of choice for axillary staging in pts dx with breast cancer in pregnancy. Isosulfan blue is classified as category C and should not be used for SLNB in pregnant pts. Several studies have collected dosimetry measurements on nonpregnant wmoen during SLNB using technetium labelled sulfur colloid. Potential radiation dose to fetus appears to be minimal and should be safe. No complications in mother or fetus were reported.

Answer 170

C C C LCIS is considered to be a marker for incr risk of breast cancer. 8x incr risk of lifetime development of breast cancer and this risk is for both breasts, regardless of which side the LCIS was identified. Pathologically, LCIS can be differentiated into classic LCIS and pleomorphic LCIS. Pleomorphic shows a more aggressive nature based on a higher proliferative index and immunohistochemical markers. LCIS is often an incidental finding. Excisional bx to r/o a coexistent malignancy is recommended. Neg margins are not required at time of surgical excision of classic LCIS; however, they are required for pleomorphic LCIS, which behaves more like DCIS. SLNB for nodal staging is not required at the time of surgical excision of LCIS and is reserved for cases with invasive disease. Adjuvant radiation is not required for classic or pleomorphic LCIS. Both classic and pleomorphic are assoc with invasive lobular carcinoma although invasive ductal carcinomas also occur in these patients.

Answer 171

``` C A A B D ``` Birads 0 Incomplete Birads 1 Neg Birads 2 Benign findings Birads 3 Probably benign--initial short interval follow up suggested Birads 4 Suspicious abN--bx should be considered Birads 5 Highly suggestive of malignancy--appropriate action should be taken Birads 6 Known biopsy--proven malignancy--appropriate action should be taken Biopsy is not required for lesions classified as birads 3. Bx is required for birads 4 lesions, and appropriate action should be take as determined by bx results. Birads 5 lesions found to be benign on core bx are considered "benign discordant" and should be excised

Answer 172

A A D ADH and ALH are both assoc with a 4x incr lifetime risk of breast cancer. Discussion regarding the use of chemoprevention is recommended to decr the risk of breast ca. Risk of breast ca is assoc with the number of foci of atypia ; breast ca risk incr with multi focal atypia FEA and papillomas with atypia are recommended for surgical excisional bx to r/o malignancy. If ADH or ALH is identified, chemoprevention should be considered; however FEA alone is not an indication for chemoprevention Papillomas with atypia have the highest risk of concurrent malignancy identified on excision, with reported rates >20%. Sclerosing adenosis is a benign finding that does not require surgical excision unless the radiologic and pathologic findings are discordant. Intraductal papilloma is the most common cause of pathologic nipple d/c and should be surgically excised to r/o concomitant malignancy.

Answer 173

C A D B Cyclical mastalgia is intermittent breast pain, sometimes quite severe, occurring in 1 or both breasts, generally in the perimenstrual period. Generally involved in a wide area of breast but it is isolated in the breast tissue, not the skin, muscle or chest wall. Noncyclical mastalgia is constant breast pain, not assoc with the menstrual cycle. Pain is less common than cyclical mastalgia and usually involves point or localized tenderness in 1 breast. Effects of estrogen on Noncyclical mastalgia are not as clear as with cyclical mastalgia. More commonly believed that anatomic rather than hormonal factors are the cause. However, menopause is a common inciting event. Evaluation of mastalgia begins with H&P. In patients of appropriate age, mammo may be necessary. If palp lesions, diagnostic mammo or U/S can assess for solid or cystic masses. Tx includes couseling to proper fitting bra, relaxation training, caffeine and tobacco abstinence, use of vit E, evening primrose oil and soy. For severe cases, adjusting of OCPs, postmenopausal estrogen replacement, Danazol, gestrinone and even tamoxifen Costochondritis is inflam of the cartilage at the costochondral or costosternal joints from ribs 2-5. Tietze syndrome is Costochondritis with assoc swelling of the joints. Physical exam will demonstrate point tenderness along the costochondral or costosternal joints. Tx with reassurance and NSAIDs. Cervial radiculopathy with compression of nerve roots primarily at C6 and C7 can be a cause of pain in the region of the breast. Not true breast pain but rather a referred pain and is commonly assoc with shoulder pain. Tx should be directed at nerve root compression.

Answer 174

B Recent study in American Journal of Gastroenterology compared morning only PEG solution with a split approach (1L 7 hrs before and 1L 4 hrs before scope) for afternoon colonoscopy. Both preps had equal clinical efficacy with respect to cleansing and polyp detection., Morning only prep was assoc with lower incidence of abdo pain, superior sleep quality and less interference with workday before scope. Greatest pt satisfaction is observed with a morning prep and an afternoon scope on the same day. Most effective cleansing is a split dose, low dose prep.

Answer 175

B Adhesive SBO is the most common cause of intestinal obstruction in pts who have undergone prev abdo ORs. During 1st episode, 70-80% will resolve with medical mgmt and therefore are not likely to require OR. RCT of long intestinal vs NG tubes showed no difference in success of non op mgmt. IV abx not necessary in SBO. Intussusception is an uncommon cause of SBO in adults and if present would require an OR b/c it is assoc with a malignant pathologic lead point in 30-50% of cases. Despite successful non op mgmt, approx 30% who have had an episode of adhesive obstruction will recur and recurrent episodes can be an indication for operation.

Answer 176

B Coffee bean sign = sigmoid volvulus. The sigmoid colon is rotated to the LUQ. Ogilvies results in a diffusely dilated colon. There are no signs or symptoms of perforation or ischemia that would necessitate operative intervention. Further, the typical elderly pt population most at risk for sigmoid volvulus often has significant comorbidities that contribute to the high morbidity and mortality (~20%) of an emergency colon resection. Therefore exp lap or cecostomy are not indicated. 75% can be decompressed with sigmoidoscopy. Water soluble contrast enema is not necessary. Neostigmine is not indicated and might result in perforation and pain.

Answer 177

C Symptoms of abdo distension, pain and constipation/obstipation are neither specific nor sensitive for specific etiology but they are a common constellation of findings in pts with acute colonic obstruction. Physical findings are non specific. Colonic obstruction can result from several different processes including mechanical (diverticular stricture or incarcerated hernia), or dynamic (toxic megacolon or colonic pseudo obstruction) causes. Colon cancer is the most common cause of LBO followed by diverticular stricture and colonic volvulus. Lack of hernia on exam typically exclude this etiology. Absence of toxic/ill appearing pt w/o fever, tachycardia or tenderness in a patient w/o abx use or IBD precludes toxic megacolon as a likely cause. These pts typically have diarrhea that is often bloody. Acute colonic pseudo obstruction (Ogilvie syndrome) is assoc with an underlying medical condition in 95% of cases or the use of certain drugs

Answer 178

C Colonic volvulus is 3rd most common cause of acute colonic obstruction and the sigmoid colon is the most commonly involved segment of colon in 66-75%. Sigmoid volvulus can present as an acute or subacute colonic obstruction and is often indistinguishable from a distal colon cancer based on symptoms. Differentiated by AXR. When dx remains in question, a gastrograffin enema is useful showing a birds beak deformity in the LLQ. In patient w/o findings concerning for ischemia or perforation, tx should begin with fluid resusc and non op decompression by rigid or flex sig and placement of rectal tube. Successful in 70-90%. Allows elective sigmoid colectomy with a primary anastomosis and complete colonoscopy to exclude a more proximal neoplasm. Definitive sigmoid resection should be done in medically fit pts during initial hospitalization b/c recurrence risk is high, occurring in at least 50%. Tube decompression allows the avoidance of resection in unprepared bowel, sparing the pt the need for a colostomy or ileostomy. Urgent colon resection is usually not indicated unless decompression fails or pt perforates.

Answer 179

C Symp of abdo distension, pain and constipation/obstipation are neither specific nor sensitive for a specific etiology but are a common constellation in patients with acute colonic obstruction. Physical findings are non specific. May result form difference processes. Acute colonic pseudoobstruction (Ogilvie's) is characterized by massive colonic dilation in the absence of mechanical obstruction. Assoc with an underlying predisposing medical condition in 95% of cases or the use of certain pharmacological agents (narcotics, anticholinergics (donepezil), CCB. B/c initial conservative mgmt of colonic obstruction, whether mechanical or Ogilvies is similar, pt should be NPO, NG, IV fluids, electrolyte correction, fluid status monitoring and potentially contributing meds d/c'ed. Ambulatory and changing the pt's position in bed are important. Conservative mgmt successful in majority of pts, neostigmine at the outset is not indicated. In addition, without clearly knowing that the pt does not have a mechanical obstruction, neostigmine is not indicated. Water soluble contrast enema is the best choice for ensuring pt does not have a mechanical cause for obstruction. Barium is a poor choice b/c of risk of ischemia/perforation and risk of barium peritoneal contamination if a perf is present. Rigid proctoscopy is unlikely to view high enough in rectosigmoid colon to r/o mechanical obstruction.

Answer 180

E GISTs are mesenchy mail tumors presenting most commonly in middle age and older patients. Surgical excision is the primary method of tx and microscopically involved margins do not affect survival. Lymphadenectomy is not required b/c GISTs rarely met to LNs. Avoid rupture of pseudocapsule during removal of GISTs Tumors at high risk of recurrence are >5 cm in diameter, have more than 5 mitosis per 50 hpfs, have ruptures, or have multiple peritoneal mets. 5 yr recurrence rates for GISTs approach 50%. GISTs are refractory to traditional chemo and radiation. GISTs are believed to arise from interstitial cells of canal, the pacemaker cells of the gut. Assoc with a high rate of mutation in kit protein, a tyrosine kinase receptor. Imatinib and sunitinib are effective as adjuvant therapy. Imatinib is approved for high risk kit positive tumors at a dose of 400 mg/day for 1 yr. In the presence of an exon 9 mutation, the dose of 800 mg/day is recommended. Sunitinib is offered as second line. This scenario describes a low risk GIST for which adjuvant therapy is not indicated. Further resection or irradiation would be of no expected benefit. Observation and serial CT is the most appropriate course of management for this pt.

Answer 181

E SRUS is a manifestation of dysfunctional evacuation and usually presents with rectal bleeding. Excessive straining causes prolapse of the rectal mucosa that results in anterior or occasionally circumferential ischemic ulceration, which may be multiple. Sphincter tone is usually N or increase. As many as 40-70% of the pts will present with a polypoid lesion which may protrude through the anal canal. The lesions are typically located 4-12 cm from the anal verge. Histologic appearance of these lesions is highly characteristic, demonstrating fibromuscular obliteration of the lamina propria with hypertrophy of the muscularis mucosal and glandular crypt abN. Previously, recurrent rectal digitalization or foreign body trauma was thought to be the cause of SRUS; this is only true in a minority. Biofeedback therapy can lead to improved anal sphincter relaxation, less straining, and more efficient defecation in patients with SRUS. SRUS should not be confused with stercoral ulceration of the rectum, which is assoc with prolonged fecal impaction.

Answer 182

C. Although Rivard says A. Adult spermatic cord sarcomas: Management and results . Annals of Surgical Oncology Volume 10, Issue 6, 2003, Pages 669-675 Liposarcomas are frequently low-grade lesions; however, their risk of local recurrence is comparable to that of high-grade lesions, and they should be aggressively treated. Patients with inadequately resected disease should undergo a reoperative procedure for wide inguinal re-resection, including completion orchiectomy or removal of the cord remnant to the internal inguinal ring with surrounding soft tissue and scar excision ade-quate to obtain a negative margin. The presence of high-grade sarcoma in these re-resected cases represents a greater risk of recurrent and metastatic disease. The definitive value of adjunctive radiation treatment or che-motherapy cannot be assessed in this small data set.

Answer 183

B Because local control is still worse with positive as compared with negative margins, reresection to negative margins is preferred if additional conservative surgery can be performed. However, re-excision must take into account the size of the re-excised field, the potential for damage or exposure of critical neurovascular structures necessitating reconstructive surgical procedures, and the fact that only a minority of margin-positive (R1) resections ever result in a local recurrence (approximately 30 percent in most series), whereas not all complete (R0) resections avoid recurrence (5 to 10 percent in most series). In major sarcoma centers, positive margins in patients with extremity lesions usually reflect tumor on the neurovascular bundle and further surgery to achieve negative margins would usually entail an amputation; most patients in this setting are treated with higher doses of adjuvant RT (in the range of 66 to 68 Gy) with amputation reserved for salvage.

Answer 184

E Enteropathy-associated T cell intestinal lymphoma (EATL), which is most often a sequela of celiac disease, is almost always of high-grade histology; the prognosis is poor and is worse than that of other intestinal lymphomas. Patients with EATL are commonly malnourished at the time of diagnosis and have a poor performance status. Treatment consists of combination chemotherapy used for other aggressive T cell lymphomas [80]. Patients who are candidates for autologous hematopoietic cell transplantation (HCT) may benefit from HCT in first remission… For patients with EATL who have a good performance status and chemotherapy sensitive disease, we suggest treatment with intensive chemotherapy followed by autologous HCT rather than chemotherapy alone.

Answer 185

A Multiple case reports/series where Whipple is used to treat isolated metastatic RCC to pancreas.

Answer 186

C WLE with 2-4cm margins to investing fascia or pericranium; reexcise until negative or clinically not feasible, in which case irradiate. MMS is an option in DFSP and FS variant. MMS goal is to achieve NEGATIVE margin, not set margins. Observe if all margins are negative. WLE is because DFSP has tentacle-like projections beyond what is clinically apparent.

Answer 187

B The use of neoadjuvant chemotherapy prior to resection of pulmonary metastases is not a widespread practice, and the decision to pursue this strategy must be made on a case by case basis or in the context of a clinical trial. For most adult-type soft tissue sarcomas, if there are concerns as to the natural history of newly diagnosed untreated metastatic disease, an alternative option is radiographic reassessment of disease status after an interval of six to eight weeks to allow the disease biology to declare itself, and spare patients with aggressive disease unnecessary surgery.

Answer 188

A For most patients with GI DLBCL, we recommend the use of combination chemotherapy plus rituximab (ie, R-CHOP) with or without involved-field RT such as that used for other patients with limited stage DLBCL rather than treatment with surgery or H pylori eradication therapy…surgery is reserved for patients with complications such as perforation or obstruction or intractable bleeding. This applies to both early stage and advanced disease.

Answer 189

D Not consented for small bowel resection. Not emergent. Other option is aborting procedure and having discussion re:bowel resection. Defer hernia until post mgmt of small bowel mass

Answer 190

D in answer key. Some controversy As thick primary melanoma (>4 mm) places patients at an increased risk for distant metastatic disease, prior dogma held that SLN biopsy or lymph node dissection was not benecial for these patients. However, a number of studies have shown that thick melanoma patients with tumor-negative SLN have a better prognosis than those with tumor-positive SLN. One review of 240 patients with melanomas more than 4-mm thick found that 58% of patients had a negative SLN biopsy, and compared with patients with a positive node, a negative biopsy was associated with both improved distant disease-free survival and overall survival. Because there is a continuum of risk that does not abruptly end at 4 mm Breslow thickness, SLN biopsy for thick melanomas may provide improved regional disease control and possibly cure for these patients. Similarly, although the benefit remains unproven, there are reports detailing SLN biopsy for some patients with locally recurrent or in-transit melanoma.

Answer 191

A on one answer key and C on the other | Doesn't mention size of lesion

Answer 192

C Higher risk for LN mets due to ulceration and Clark IV

Answer 193

A Spitz naevi are benign skin tumours. However, they may resemble malignant melanomas clinically and microscopically, so they are often excised as a precaution. Skin lesions with clinical features of Spitz tumors should be removed by simple excision if there is concern for an atypical melanocytic lesion or melanoma. We suggest margins of approximately 3 to 5 mm. Atypical Spitz tumors with positive margins should undergo reexcision to achieve clear margins given the difficulty in definitively distinguishing atypical Spitz tumors from melanoma.

Answer 194

B Multiple bilobar is classical contraindication to resection. Cytoreduction may be effective if can achieve 90% resection with FLR >20%

Answer 195

C Wouldn’t compromise limb function without definitive diagnosis, but in this location should be resectable without neurovascular compromise.

Answer 196

C Jejunoileal site has lowest 5-yr survival. Prognosis of gastrointestinal smooth-muscle (stromal) tumors: dependence on anatomic site Am J Surg Pathol, 23 (1999), pp. 82–87 Gastric GISTS, the largest group, comprising nearly two-thirds of all GISTs, generally have a better survival than small intestinal GISTs of similar size and mitotic activity. Can’t find anything to stratify prognostic features of size & mitotic index, but SB GIST clearly has worse prognosis.

Answer 197

D Do 2 cm margin unless cosmetically unaccepatble then would do 1 cm

Answer 198

A If it was a clinically palpable LN pre-op, do superficial groin LN dissection Otherwise do SLN, await definitive path and if positive have discussion with patient re groin dissection in light of MSLT 2

Answer 199

B Fine-Needle Aspiration Biopsy: - Cannot differentiate between adrenal adenoma and adrenocortical carcinoma - Can differentiate between adrenal tumour and metastatic disease - Therefore clinically indicated if known malignancy or suspected malignancy outside of adrenal12 - MUST rule out pheochromocytoma prior to biopsy and is ONLY indicated if high suspicion of metastatic disease that cannot be documented by biopsy of other tissue If this was an melanoma met to adrenal Resection of metastases to endocrine organs may provide palliation and prolong survival for symptomatic patients [21,22]. In one report, 18 of 27 patients (67 percent) with adrenal metastases from melanoma were rendered disease free surgically; the median survival was 26 months following complete resection compared with nine months after palliative resection. Laparoscopic adrenalectomy for metastatic disease is safe, effective, and associated with less morbidity than the open approach.

Answer 200

A If high risk features then 1 cm margin

Answer 201

E Low risk if small, 2-5% if large nevi, higher in giant CMN.

Answer 202

A Histologically, cutaneous metastases appear as nodules in the dermis or subcutaneous fat without an epidermal connection.

Answer 203

E Whenever possible, subungual melanomas of the fingers should be resected at the distal interphalangeal joint to preserve function [53]. Melanomas located more proximally on the fingers can often be managed with wide local excision of soft tissue, skin grafts, or local flaps for soft tissue coverage. Subungual melanomas involving the toes can be managed easily with digital amputation at the metatarsal-phalangeal joint. If the first toe is involved, complete amputation should be avoided when oncologically feasible because of the importance of the toe in balance.

Answer 204

C There is general consensus that incisional biopsy may be occasionally acceptable for very large lesions or for certain sites, including the face, palm or sole, ear, distal digit, or subungual lesions

Answer 205

A RF: greater age at transplant, UV exposure, pre-transplant skin CA, HPV, type of transplant (liver is least). More likely to develop multiple and more aggressive tumours. SCC most common

Answer 206

A UTD There is ongoing controversy about the need for surgical excision when radial scars are found on core biopsy. We suggest that these be excised since most series show that 8 to 17 percent of surgical specimens at subsequent excision are positive for malignancy.

Answer 207

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

Answer 208

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

Answer 209

C Presumably cardiac dysfunction related to chemo PE shouldn't cause cardiomegaly

Answer 210

A UTD: 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 211

B in the answer key But lumpectomy requires radiation to have equivalent outcome. Could do modified radical mastectomy with SLNB. But technically you could bx LN and if positive, treat with neoadjuvant chemo then lumpectomy and give radiation post partum

Answer 212

A Lupus is a relative contraindication to radiation

Answer 213

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 214

D Presuming they already did an U/S? Otherwise how do they know the characteristics of the lesion???

Answer 215

A When combined with use of intraoperative PTH monitoring, minimally invasive parathyroidectomy techniques result in excellent outcomes that are comparable to a traditional bilateral cervical exploration [23-27]. Localization results inform the surgeon where to start looking for the adenoma, and intraoperative PTH results suggest to her/him when to stop looking.

Answer 216

B In middle-age and older, SCC >>> BCC, so have to assume that’s what its. Well-differentiated SCC can look bland. Lymphocytes confirm this is within a lymph node, which is less likely with BCC. Remains controversial due to bland cytology, but we decided to go with an age-based probability.

Answer 217

B UTD: Women with differentiated thyroid cancer require surgery. However, given the typically indolent nature of thyroid cancer, thyroidectomy is usually delayed until the postpartum period to minimize maternal and fetal complications [55,61]. This approach does not appear to have a negative impact on prognosis When surgery for biopsy-proven thyroid cancer is deferred, the patient should be monitored during pregnancy with thyroid ultrasound performed during each trimester. If, by 24 weeks, there is a significant increase in thyroid cancer size (50 percent in volume or 20 percent in diameter in two dimensions), surgery should be performed during the second trimester [9,46]. However, if the size remains stable or if it is diagnosed in the second half of pregnancy, surgery may be performed after delivery. In such cases where thyroid surgery is deferred, we suggest thyroid hormone suppressive therapy with a goal of maintaining the TSH in the range of 0.3 to 2.0 mU/L. Surgery during pregnancy is sometimes indicated for rare patients with larger, more aggressive or rapidly growing cancers or in the presence of extensive nodal or distant metastasis. The safest time for any type of surgery during pregnancy is the second trimester

Answer 218

A Medullary thyroid carcinoma--> amyloid on FNA. ATA unclear on w hether to do a prophylactic lateral LND if clinically negative, but size >2cm is reasonable to do it. Overall, the approach is to do neck ultrasound and calcitonin levels. Best answer is probably to do total and central LND (ATA 26), no lateral LND unless clinically/ radiographically positive OR CEA >200.

Answer 219

A 13%, most commonly in thymus.

Answer 220

B Carotid duplex scan can localize the tumor to the carotid bifurcation, but CT or MRI is usually required to further delineate the relationship of the tumor to the adjacent structures.

Answer 221

A B=bad; thyroidectomy before age 2.

Answer 222

C ATA If the reading is ‘‘suspicious for papillary carcinoma’’ or ‘‘Hurthle cell neoplasm,’’ a radionuclide scan is not needed, and either lobectomy or total thyroidectomy is recommended, depending on the lesion’s size and other risk factors. Recommendation rating: A

Answer 223

B ATA RECOMMENDATION 26: For patients with thyroid cancer >1 cm, the initial surgical procedure should be a near-total or total thyroidectomy unless there are contraindications to this surgery. Thyroid lobectomy alone may be sufficient treatment for small (<1 cm), low-risk, unifocal, intrathyroidal papillary carcinomas in the absence of prior head and neck irradiation or radiologically or clinically involved cervical nodal metastases. RECOMMENDATION 29: Completion thyroidectomy should be offered to those patients for whom a near-total or total thyroidectomy would have been recommended had the diagnosis been available before the initial surgery. This includes all patients with thyroid cancer except those with small (<1 cm), unifocal, intrathyroidal, node-negative, low-risk tumors. RECOMMENDATION 40: Initial TSH suppression to below 0.1mU=L is recommended for high-risk and intermediate-risk thyroid cancer patients, while maintenance of the TSH at or slightly below the lower limit of normal (0.1–0.5mU=L) is appropriate for low-risk patients. Similar recommendations apply to low-risk patients who have not undergone remnant ablation, i.e., serum TSH 0.1–0.5mU=L.

Answer 224

C LLND is reasonable but not mandated by guidelines; in presence of bulky CC nodal disease or >2cm primary OR calcitonin <200, LLND is very reasonable but no consensus was reached

Answer 225

D Primary HyperPTH – normal or high urinary Ca, unless concomitant Vit D deficiency Secondary HyperPTH – no, would have high phosphate Tertiary HyperPTH – low phosphate PHPT with Vit D deficiency can also cause low urinary Ca and hypercalcemia.

Answer 226

A RECOMMENDATION 61: Patients with known or highly suspected MTC with no evidence of advanced local invasion by the primary tumor, no evidence cervical lymph node metastases on physical examination and cervical ultrasound, and no evidence of distant metastases should undergo total thyroidectomy and prophylactic central compartment (level VI) neck dissection (Grade B recommendation).

Answer 227

A UTD Many centers collect an extra sample at the time of the initial biopsy to be used for molecular testing should the cytology be read as FLUS or AUS (or follicular neoplasm). Other centers follow the original recommendations of the Bethesda Conference [39] and repeat the cytology after a three to six-month interval (or earlier), and they obtain molecular testing only if the second biopsy remains in the FLUS or AUS (or follicular neoplasm) category. If molecular testing is unavailable and repeat aspirates continue to show atypical cells, we suggest diagnostic surgery (typically thyroid lobectomy). Indeterminate cytology, reported as ‘‘follicular neoplasm’’ or ‘‘Hurthle cell neoplasm’’ can be found in 15–30% of FNA specimens (4) and carries a 20–30% risk of malignancy (42), while lesions reported as atypia or follicular lesion of undetermined significance are variably reported and have 5–10% risk of malignancy

Answer 228

C Pyoderma gangrenosum is a rare but serious ulcerating skin process, which generally starts as small papules most frequently on the lower extremities, then progresses to small ulcers with a cat's paw appearance. The ulcers coalesce t form larger ulcerations with necrotic centers. Pathergy in 25-50% = developement of nonhealing ulcers in response to minor trauma. Surgical debridement should be avoided for this reason. Dx based on clinical findings. Peristomal PG can be extremely morbid, esp in patients who are not candidates for reversal of the stoma. Relocation may be followed promptly by another outbreak of peristomal PG. Majority of pts with peristomal PG have active Crohn's disease. All patients with peristomal PG should undergo evaluation for IBD. If colostomy or ileostomy reversal is not feasible, successful tx can be achieved with immunosuppressive agents such as corticosteroids, cyclosporine or infliximab. Topical nystatis would be of no benefit.

Answer 229

E C diff produces 2 large single unit toxins: A and B. In animal models, toxin A is able to elicit may of the symp of C diff assoc disease alone, whereas toxin B requires small amts of co-administered toxin A or an intestine that has been damaged by physical manipulation. No real gold standard for dx, stool culture and cell cultures cytotoxicity neutralizaion assay for toxin B are usually used as reference standards when evaluating a new diagnostic test. Both can be difficult to perform and take up to several days to complete, leading to the search for a more rapid test that is both appropriately sensitive and cost effective. CT usually abN in patients with fulminant colitis. Considering the spectrum of CDAD, specific findings on CT do not correlate with either disease severity of need for surgical intervention. CT may be normal in half of the patients. Proctoscopy, once thought to be a hallmark of dx, may be unrevealing in up to 15%of patients with fulminant disease and more pts with milder disease. Stool cytotoxin enzyme immunoassay has a sensitivity of 60-80%, most likely b/c of its inability to detect specific ribotypes. These types are detected by stool PCR, which has a sensitivity of 90-100%. PCR detects more cases of C diff b/c of the significantly improved sensitivity over the more common enzyme immunoassay that is currently most commonly used. Another advantage of PCR is the need for only a single sample and the rapidity with which the results are available. However, the overall usefulness of the test and its cost effectiveness depend on the prevalence of the disease in a particular population or area, b/c it does not distinguish between asymp carrier and those with symptomatic disease

Answer 230

B RAI--definitive treatment prior to elective surgery; goal is to treat Graves and make euthyroid BB with lugols – only if urgent or non-postponeable surgery, only for within 10 days of surgery For patients with Graves’ hyperthyroidism who are allergic to or are intolerant of thionamides, the combination of beta blockers and iodine can be used for preoperative preparation. Patients with toxic nodular goiter who are allergic to or are intolerant of thionamides should be treated with beta blockers alone, as iodine may worsen hyperthyroidism. NG: This is only for patients requiring urgent surgery While thionamides alone are sufficient to achieve euthyroidism in approximately three to eight weeks, we suggest adding iodine (potassium iodide solution, SSKI, one to five drops three times daily) at least one hour after thionamides are administered, if hyperthyroidism is severe and the need for surgery is urgent. Iodine blocks release of T4 and T3 from the gland and thereby shortens the time to achieving a euthyroid state. This effect, however, may be transient, and the use of iodine to block release of hormone beyond 10 days is not generally recommended; it can be started 10 days preoperatively for urgent procedures that are scheduled more than 10 days in the future, but which cannot be delayed until the patient is chemically euthyroid following a thionamide.

Answer 231

A TE Groove and Carotid sheath are for superior. Intrathyroidal is least common inferior ectopic position

Answer 232

C We suggest unilateral lobectomy and isthmusectomy when a unifocal tumor is less than 1.0 cm in diameter (microcarcinoma) and confined to one lobe of the gland. The 30-year survival rate for this subgroup of patients approaches 100 percent. Thyroid hormone suppression — After initial thyroidectomy, whether or not radioiodine therapy is administered, levothyroxine therapy is required for all patients to prevent hypothyroidism and to minimize potential TSH stimulation of tumor growth. Our recommendations for initial thyroid hormone suppression therapy are as follows: For ATA low risk disease (table 2) – The serum TSH can be maintained between 0.1 and 0.5 mU/L until the patient demonstrates an excellent response to therapy (usually within the first 6 to 12 months) at which point the TSH can be kept at or slightly below the lower half of the reference range (0.3 to 2.0 mU/L).

Answer 233

B Small benign euthyroid goiters do not require treatment. The effectiveness of medical treatment using thyroid hormone for benign goiters is controversial. Medical options for treating goiter include iodine replacement, thyroid-hormone replacement, thyroid-hormone suppressive therapy, and radioactive iodine treatment. However these do not prevent growth. Surgery is reserved for the following situations: - Large goiters with compression - Malignancy - When other forms of therapy are not practical or ineffective

Answer 234

A If the mandibular branch of the facial nerve is injured it results in a flattening of the lower lip on the affected side. Structures at risk during submandibular gland excision: • facial vein • marginal mandibular n. • lingual nerve (V) • hypoglossal n.

Answer 235

C in answer key. But I thought A Imaging & ioPTH reduces operative time and smaller incision with equal accuracy If hereditary PHPT, 4-gland exploration required so imaging not necessary Bilateral exploration in 2⁰ or 3⁰ HPT

Answer 236

C In general, the ratio of benign to malignant tumours is proportional to the gland size; i.e. the parotid gland tends to have benign neoplasms, the submandibular gland 50:50, and the sublingual glands and accessory glands mostly malignant. Due to the size discrepancy, in absolute numbers the parotid gland has the most tumours. Pleomorphic adenoma: this is the most common (≈50%) tumour of the parotid Warthin tumour: essentially only found in the parotid, in older, usually male, patients; it is bilateral in 10-15% Mucoepidermoid carcinoma: most of the malignant lesions

Answer 237

C UTD: Three pronged approach -Volume expansion with isotonic saline at an initial rate of 200 to 300 mL/hour that is then adjusted to maintain the urine output at 100 to 150 mL/hour. -Administration of salmon calcitonin (4 international units/kg) and repeat measurement of serum calcium in several hours. If a hypocalcemic response is noted, then the patient is calcitonin sensitive and the calcitonin can be repeated every 6 to 12 hours (4 to 8 international units/kg). We typically administer calcitonin (along with a bisphosphonate) in patients with calcium >14 mg/dL who are also symptomatic. -The concurrent administration of zoledronic acid (ZA; 4 mg intravenously [IV] over 15 minutes) or pamidronate (60 to 90 mg over two hours), preferably ZA because it is superior to pamidronate in reversing hypercalcemia related to malignancy. The administration of calcitonin plus saline should result in substantial reduction in serum calcium concentrations within 12 to 48 hours. The bisphosphonate will be effective by the second to fourth day, thereby maintaining control of the hypercalcemia. -n the absence of renal failure or heart failure, loop diuretic therapy to directly increase calcium excretion is not recommended, because of potential complications and the availability of drugs that inhibit bone resorption, which is primarily responsible for the hypercalcemia. Additional, more aggressive measures are necessary in the rare patient with very severe, symptomatic hypercalcemia. Hemodialysis should be considered, in addition to the above treatments, in patients who have serum calcium concentrations in the range of 18 to 20 mg/dL (4.5 to 5 mmol/L) and neurologic symptoms but a stable circulation or in those with severe hypercalcemia complicated by renal failure. (See 'Dialysis' below.)

Answer 238

A Gluconate has less risk of tissue necrosis if extravasates; can’t give faster than 10 minutes as risk of cardiac arrest!

Answer 239

B Thyroglobulin (Tg) is a large glycoprotein that is synthesized in thyroid follicles and serves as the precursor of thyroid hormone (T4). Small amounts of thyroglobulin are secreted into the serum of normal individuals. Serum levels are proportional to thyroid size. Destruction of thyroid follicles by inflammation or neoplasia results in an increase in serum Tg concentrations. Following thyroid surgery, serum Tg concentrations fall rapidly with a half-life of 2 to 4 days. Any Tg released from surgical margins should disappear within the first month after surgery. During this time TSH is the dominant influence on serum Tg level. If thyroid hormone therapy is initiated immediately before surgery to prevent the rise in TSH, serum Tg concentration will decline to a level that reflects the size of the normal thyroid remnant plus any residual or metastatic tumor. Measurement of TSH-stimulated serum Tg, using either T4 withdrawal or rhTSH stimulation, at a time point between 6 and 12 months following the initial treatment; a stimulated serum Tg of less than 1 ng/ml is considered to indicate probable cure. The US recommendations view a serum Tg concentration of more than 2 ng/ml, unstimulated or stimulated, as suggestive of possible residual or recurrent disease in athyrotic patients.

Answer 240

B Before 1893, the removal of a thyroglossal cyst included simple incision and drainage. The recurrence rate after this procedure was ∼50%. In 1893, Schlange proposed the excision of the cyst along with the central portion of the hyoid bone. This resulted in a drop in the recurrence rate to 20%. However, in 1920, Walter Sistrunk took this operation one step further and recommended not only taking the central portion of the hyoid bone but also carving out a core or tissue one eighth of an inch in radius from the hyoid bone to the foramen cecum.

Answer 241

A Indications for total thyroidectomy -RAI planned, >4 cm, extrathyroidal extension, regional/distant mets, contralat nodules, prior radiation, hx of familial DTC Indications for ppx central LN dissection -tumor > 4 cm, gross extrathyroidal extension lateral neck nodal diseae

Answer 242

D Salivary gland much more likely to have adenoca Mets to Jugulodigastric/upper jugular from epipharynx, base of tongue, tonsils, nasopharynx, larynx If SCC – tonsils/base of tongue

Answer 243

C in answer key. Nason agrees D is more consistent with Sabiston Sabiston En bloc resection of tumor with ipsilateral thyroid lobectomy and compartment oriented LN dissection

Answer 244

C in answer key Nason says amyloid likely indicates medullary thyroid cancer. Don't need lateral neck dissection unless postive

Answer 245

A Need to r/o pheo--would treat this first Other things to do: Clinical exam, neck U/S, calcium, calcitonin, PTH, systemic staging if calcitonin >500, RET testing & genetic counselling. 75% are sporadic.

Answer 246

A Magnesium deficiency causes hypocalcemia by interfering with the end-organ actions of PTH and/or by inhibiting its secretion

Answer 247

A and B In order to minimise the risk of injury to the nerve, one should incise skin and platysma at least 3cms below the mandible. Critical step to ID MM nerve.

Answer 248

A Establish diagnosis first, SVC syndrome treated medically or with RT if that is what this is. Subacute thyroiditis can also present (not as dramatically) but similarly, and FNA is diagnostic.

Answer 249

C. Although CT and MRI are also both useful modalities Warthin tumours, also known as lymphomatous papillary cystadenomas, are benign, sharply demarcated tumours of the salivary gland. They are of lymphoid origin and most commonly arise from parotid gland tail. They may be bilateral or multifocal in up to 20% of cases and are the most common neoplastic cause of multiple solid parotid masses. Warthin tumours are the 2nd most common benign parotid tumour (after pleomorphic adenoma) and represent up to 10% of all parotid tumours. They are the commonest bilateral or multifocal benign parotid tumour. They typically occur in the elderly (6th decade) with a recognised male predilection. Patients typically present with painless parotid swelling. Radionuclide scanning with [@Tc]pertechnetate is a simple and noninvasive method for assessing salivary glandfunction. It is a suitable radioactive tracerfor human use because of its short half-life of 6 hr and pure gamma emission of 140keV, which is readilydetected by a gamma camera(4). Thetechniqueiswell describedin theliterature (4,5,10) and involves imaging of the parotid gland in the posterior projection after the intravenous infusion of 5 mCi of the tracer at 60-secintervals for 20 min and obtaining final images of the patient in water, right lateral and left lateral positions, followed by washout images obtained 3 min after stimulationwith orally administeredlemon juice to determineadequacyand symmetiy of glandularsecre tion. Nonfunctioning lesions are usually suggestive of carcinoma, mixed tumors or cysts, whereas hyperfunctioning intrinsic lesions frequently represent Warthin's tumors. A normalwashout phase is char acterized by accumulation of radioactivity within the oral cavity following a secretory stimulus. Delays in this drainage pattern may result from obstructed glands, whereas local retention within the gland is strongly supportive of a Warthin's tumor. This pattern is quite typically seen with Warthin's tumor because the tumor is capable of concentrating the tracer, but cannot secrete it since the tumor does not communicate with the gland's ductal system

Answer 250

C Other questions have listed A as an answer for an older patient SCC histologically shows presence of keratin, monofilament bundles, or desmosomes,

Answer 251

E SIMPLE ENUCLEATION OF PAROTID TUMOURS Parotid gland tumours are the most common salivary gland tumours. The most common histological subtype is a pleomorphic adenoma, which accounts for 65%, followed by Warthin’s tumour, which accounts for about 25% of all parotid tumours. Other adenomas, such as basal cell adenomas and oncocytomas, are far less common. The reason for the high recurrence in simple enucleation for pleomorphic adenomas is believed to be the violation and spillage in cutting of microprojections of the tumour that protrude through its pseudocapsule Frey's syndrome (also known as Baillarger’s syndrome, Dupuy’s syndrome, auriculotemporal syndrome, or Frey-Baillarger syndrome) is a rare neurological disorder resulting from damage to or near the parotid glands responsible for making saliva, and from damage to the auriculotemporal nerve often from surgery. The symptoms of Frey's syndrome are redness and sweating on the cheek area adjacent to the ear (see focal hyperhidrosis). They can appear when the affected person eats, sees, dreams, thinks about or talks about certain kinds of food which produce strong salivation.[citation needed] Observing sweating in the region after eating a lemon wedge may be diagnostic.

Answer 252

B The superior laryngeal nerve consists of two branches: the internal laryngeal nerve (sensory), which supplies sensory fibers to the laryngeal mucosa, and the external laryngeal nerve (motor), which innervates the cricothyroid muscle. The external laryngeal nerve is the smaller, external branch. It descends on the larynx, beneath the sternothyroid muscle, to supply the cricothyroid muscle. The external branch functions to tense the vocal cords by activating the cricothyroid muscle, increasing pitch.

Answer 253

E The neck has traditionally been divided into three anatomic zones when describing penetrating neck trauma, which guides clinical management : zone 1: from the level of the clavicles and sternal notch to the cricoid cartilage important structures include the aortic arch, proximal carotid arteries, vertebral arteries, subclavian vessels, innominate vessels, lung apices, oesophagus, trachea, brachial plexus and thoracic duct zone 2: from the cricoid cartilage to the angle of the mandible important structures include the common, internal and external carotid arteries, the jugular veins, larynx, hypopharynx and proximal oesophagus zone 3: from the angle of the mandible to base of skull important structures include the internal carotid artery, vertebral artery, external carotid artery, jugular veins, prevertebral venous plexus and facial nerve trunk

Answer 254

D Killian's triangle, located superior to the cricopharyngeus muscle and inferior to the Thyropharyngeus muscle. Thyropharyngeus and Laryngopharyngeus are the superior and inferior parts of inferior constrictor muscle of pharynx respectively

Answer 255

E Warthin tumours, also known as lymphomatous papillary cystadenomas, are benign, sharply demarcated tumours of the salivary gland. They are of lymphoid origin and most commonly arise from parotid gland tail. They may be bilateral or multifocal in up to 20% of cases and are the most common neoplastic cause of multiple solid parotid masses. Warthin tumours are the 2nd most common benign parotid tumour (after pleomorphic adenoma) and represent up to 10% of all parotid tumours. They are the commonest bilateral or multifocal benign parotid tumour. They typically occur in the elderly (6th decade) with a recognised male predilection. Patients typically present with painless parotid swelling. Warthin tumour on pathology shows two-layered oncocytic epithelium forming closely packed tubules accompanied by a lymphoid stroma

Answer 256

A Frey's syndrome (also known as Baillarger’s syndrome, Dupuy’s syndrome, auriculotemporal syndrome, or Frey-Baillarger syndrome) is a rare neurological disorder resulting from damage to or near the parotid glands responsible for making saliva, and from damage to the auriculotemporal nerve often from surgery. The symptoms of Frey's syndrome are redness and sweating on the cheek area adjacent to the ear (see focal hyperhidrosis). They can appear when the affected person eats, sees, dreams, thinks about or talks about certain kinds of food which produce strong salivation.[citation needed] Observing sweating in the region after eating a lemon wedge may be diagnostic.

Answer 257

A There are three nerves that lie close to the submandibular gland. The following three nerves can be damaged all with varying results: •Weakness of the lower lip - a lower branch of the facial nerve/CN VII (the marginal mandibular branch) •Numbness of the tongue - the lingual nerve (CN V3) •Restricted tongue movement - the hypoglossal nerve (CN XII)

Answer 258

A Mucoepidermoid carcinoma is the most common malignant tumor of the parotid gland, accounting for 30% of parotid malignancies. Three cell types are found in varying proportions: mucous, intermediate, and epidermoid cells. High-grade tumors exhibit cytologic atypia, higher mitotic frequency, areas of necrosis and more epidermoid cells. High-grade tumors behave like a squamous cell carcinoma; low-grade tumors often behave similar to a benign lesion. Limited local invasiveness and low metastatic potential characterize this tumor, particularly when cytologically low-grade. If metastatic, it is most likely to metastasize to regional nodal basins rather than to distant locations. For patients with low-grade tumors without nodal or distant metastasis, 5-year survival is 75-95%, whereas patients with high-grade tumors with lymph node metastasis at the time of diagnosis have a 5-year survival of only 5%. Overall 10-year survival is 50%. Adenoid cystic carcinoma is characterized by its unpredictable behavior and propensity to spread along nerves. It possesses a highly invasive quality but may remain quiescent for a long time. This tumor may be present for more than 10 years and demonstrate little change and then suddenly infiltrate the adjacent tissues extensively.

Answer 259

D Infected panc necrosis is a life threatening condition with mortality rates > 20%. In addition to initiation of IV abx, therapy, must include prompt surgical debridement of the dead, infected tissue to obtain adequate source control. Although perc drain followed by minimally invasive retroperitoneal necrosectomy was used by the Dutch Pancreatitis Study Group as a tx option, exp lap with open necrosectomy remains the standard therapy. Mortality is similar for each approach. Necrosectomy is necessary only in the setting of infection. In cases of sterile necrosis, non op supportive care is sufficient, included resusc, nutritional support, and adjunects to support organ function. Panc pseudocysts are peripancreatic fluid collections surrounded by a dense fibrous wall lacking epithelial lining. They contain high concentrations of pancreatic enzymes and require drainage. Often, drainage can be achieved via endoscopic techniques such as endoscopic cyst gastrostomy or an open Roux-en-Y cyst jejunostomy.

Answer 260

A Pneumatosis intestinalis = air contained within the submucosa of the intestinal wall, can vary from benign to significant, life threatening intra-abdominal pathology. CT shows extensive pneumatosis as well as air in the mesenteric vasculature. Mesenteric ischemia is the most common cause of life threatening pneumatosis intestinalis. B/c the patient has signs and symptoms of abdominal sepsis, emergence laparotomy is indicated to evaluate for intestinal ischemia. Although acute mesenteric ischemia has a low incidence (1 in 1000 patients admitted to hospital), mortality rates can approach 70%. Primary mesenteric ischemia includes vascular etiologies, such as occlusive (SMA embolism, SMA thrombosis and SMV thrombosis), and low flow (nonocclusive mesenteric ischemic conditions). Secondary mesenteric ischemia have non vascular origins including SBO or volvulus. CT has high sensitivit and specificity for both forms.

Answer 261

D Non op management of complicated appendicitis, defined as appendiceal abscess or phlegmon, is assoc with decr complication and reoperation rates compared with immediate appendectomy. After initial non op management for appendicitis, interval appendectomy was traditionally advocated b/c of perceived risk of recurrent appendicitis. Given this patient's advanced age, a potential etiology of a RLQ inflammatory mass is a perforated colon cancer, therefore, colonoscopy is required. Routine interval appy is not necessary. Since the patient is asymptomatic in term of her appendix, repeat CT abdo or diagnostic laparoscopy is not required. CRP is likely to be incr in patients with infection or inflammation.

Answer 262

E Meckel's is the most common congenital abN of the small intestines, resulting from incomplete obliteration of the vitelline duct in the 5th to 7th week of life. It is a true diverticulum, involving all 3 intestinal layers. Typically arise on the antimesenteric border of the bowel. Often described by the rule of 2s: 2% of population, within 2 feet of IC valve, and approx 2 inches long. They can also contain ectopic gastric mucosa and pancreatic mucosa Common complications related to Meckel's includ GI bleeding (often seen in children), obstruction due to intussusception or an adhesive band, ulceration, diverticulitis, and perforation. Tx of a symptomatic Meckel's involves diverticulectomy or segmental resection of the involved segment of bowel. Segmental resection is required in cases of bleeding b/c the source of bleeding is typically the normal bowel opposite the mouth of the diverticulum. A challenge is the management of an asymptomatic Meckel's diverticulum found incidentally on abdominal exploration. Traditional teaching advocated resection in all patients but more recent data suggest they should be left is situ, especialy in older patients. Study noted higher postop complications in patients undergoing resection of an incidental Meckel's diverticulum compared with those left in situ. No late complications were noted in diverticulum left in situ. Number needed to treat of 758 patients to prevent 1 death due to indicental Meckel's

Answer 263

A PUD remains the most common cause of GI perf, occurring in up to 10% of patients with ulcers. RF for perf include presence of H pylori infection, smoking, NSAID use, and EtOH. Patients typically present with acute onset severe abdo pain and signs of peritonitis. Upright CXR may demonstrate free air under the diaphragm. Mortality has remained stable over the last 2 decades ranging from 6-14% and morbidity is up to 63% in some studies. Major medical illness, incr age, preop hypotension, delay in sx >24 hrs, and post op infection (ie abdo or wound) are all assoc with worse outcomes. Mortality rates of patients > 70 can approach 40% Initial management of pts with perf ulcers consists of NG tube decompression, aggressive IV fluid resusc, IV Abx, and urinary catheter to monitor output. Prompt OR intervention is the norm, except in well defined subset of pts in which conservative mgmt is an option. These patients must be hemodynamically stable, free of genrealized peritoneal signs, and have a contained leak or sealed perf on Gastrograffin upper GI exam. They should be >70 yr and onset of symp within 24 hrs. Such patients should receive IV PPI in addition to management steps outlined. Patients are monitored with serial abdo exams. If a patient's condition does not improve within 12 hrs or if any clinical deterioration occurs, prompt OR is indicated. Truncal or selective vagotomies +/- pyloroplasty have been abandoned in favor of perforation closure with tx of H pylori infection and PPI initiation. Graham patch closure of the perforation site, in which an omental tongue is placed over the perforation and sutured into place, remains the procedure of choice for most surgeons. It can be performed open or laparoscopic. Pyloroplasty alone is not a therapeutic option. Prepyloric ulcers are tx in the same manner as duodenal ulcers. Bx or ulcer excision (if feasible) of gastric ulcers should be undertaken to r/o malignancy

Answer 264

B Neuroendocrine tumors are classified according to their anatomic site of origin and by their embryologic derivation. NETs with serotonin, histamine, or amine producing tumors are commonly referred to as carcinoid tumors. They can arise in foregut, midgut and hindgut. Often appendiceal carcinoids present as acute appendicitis and are discovered retrospectively on pathological analysis of the resected specimen. Of these tumors, approx 10% involve the base of the appendix; the majority of tumors are located in the tip of the appendix. 18% of appendiceal carcinoids have GI malignancies. Mortality is strongly assoc with the size of the tumor, with 5 yr mortality climbing from approx 5% to 29.5% for 1 and 2 cm tumors. Given this, R hemi is recommended for tumors at least 2 cm. 30% will have + LNs. Other indications for completion hemicolectomy include incomplete initial resection, unknown tumor size, LVI, invasion of mesoappendix, higher grade tumors (i.e. intermediate or high) and mixed histology (i.e. goblet cell or adenocarcinoid). WIthout these RF, appendectomy alone is sufficient in pts with tumors <2 cm. Octreotide and interferon alpha are indicated to tx carcinoid syndrome

Answer 265

C Lap sleeve gastrectomy involved a longitudinal (vertical) resection of the stomach from just proximal to the pylorus up to the angle of His, creating a tube like structure along the lesser curve. Resection is typically undertaken using a stapler. Wt loss, comborbidity resolution, and mortality for LSG is comparable to lap RYGB. Resection of the majority of the stomach turns the remaining gastric tube into a high pressure system. This fact, combined with the long resection/staple line, make gastric leak 1 of the most frequent complications for this procedure approaching 0.9%. Intraop inspection of the staple line is recommended to ensure no leak. Other complications include stricture formation (0.7%), bleeding (0.4%), PE (0.3%), delayed gastric emptying (0.3%), intra abdo abscess (0.1%), surgical site infection (0.1%), splenic injury (0.1%) and trocar site hernia (0.1%). Revision rates approach 4%.

Answer 266

A Hematogenous spread to the liver occurs in 40-60% pts with CRC. The only potential for cure is surgical resection. Single center and multicenter studies demonstrate the same results, with resection giving a 48 month media survival. OR mortality varies between 1-3%, depending on patient selection, institutional experience and incidence of major vs minor resections in the study. Median survival with chemo for isolated liver mets is approx 20 months. Addition of biologic agents improves survival slightly. RFA should be reserved for lesions < 5 cm with a contraindication for surgery.

Answer 267

B The accessory duct of the pancreas is the vestigial proximal portion of the dorsal pancreatic duct resulting from incomplete fusion of the ducts of the dorsal and ventral pancreas during fetal development. The accessory duct typically opens through the lessor or minor papilla also known as the duct of Santorini. In most cases, the accessory duct of the pancreas remains in continuity with the main pancreatic duct and may be occluded before opening into the duodenum. Obstruction does not cause clinical sequelae. However in 4-14% of individuals with pancreas divisum, obstruction of the accessory duct may cause pancreatitis.

Answer 268

A Most CBD injuries are missed at the time of initial operation and present postop with abdo pain, swelling and fever. With the advent of ERCP, need to detect and clear retained stones at the time of sx are no longer mandatory. IOC are performed by a variety of anatomic approaches (via gallbladder, cystic duct, or direct puncture) and technical/radiographic techniques (fluoro, single shot film). Full delineation of biliary tree may be limited by inflammation and other factors. Minimal necessary elements include: delineation of the hepatic bifurcation and first order intrahepatic radicals (sectoral), full opacification of the extrahepatic bile ducts, and flow of contrast into the duodenum. No clear benefit to routine IOC b/c it does not reduce the frequency or severity of injuries.

Answer 269

C ERAS is a multidisciplinary effort designed to enhance patient's post op experience and to reduce the length of hospitalization. Includes limiting intraop fluid administration, using epidural analgesia, minimizing IV narcotics, early diet, early ambulation, and providing post op education. Assoc with shorter hospitalization without increases in morbidity. The critical end points that drive recovery and dismissal from hospital in most patients are 1) control of pain and 2) return of oral intake and bowel function. Most studies demonstrate reductions in reported pain. Most studies show a reduced length of stay without an increase in readmission rates (5%). ERAS reduced the length of stay for open colectomys by approx 2 days compared with conventional postop care. The benefit is greater for open procedures than for laparoscopic.

Answer 270

1. B 2. D 3. A 4. C 5. B Primary esophageal motility disorder includes achalasia, diffuse esophageal spasm, nutcracker esophagus, and hypertensive lower esophageal sphincter. They have specific manometric patterns and dysmotility is considered responsible for the assoc symptoms. GERD can cause secondary esophageal changes related to the reflux Achalsia is characterized by a loss of peristalsis in the distal esophagus and failure of the LES to relax. Resting LES pressure is elevated in ~1/2 of patients. Symptoms are primarily related to failure of LES to relax, which causes functional obstruction at the distal esophagus and sensation of dysphagia. Dysphagia for both solids and liquids is a primary feature with dysphagia with liquids being the most characteristic. Most common primary motility disorder. DES characterized by discoordinated esophageal motliity seen as simultaneous contraction (>20% wet swallows), intermittent peristalsis, repetitive contractions (>3 peaks) with contraction amplitudes >than 30 mm Hg for longer duration > 6 secs. Symp usually manifest as dysphagia or chest pain but can include heartburn and regurg, making them difficult from other etiologies, such as GERD based on symp alone. DES is a rare motility disorder. Nutcracker esophagus is characterized by peristaltic waves in the distal esophagus of high amplitude (>180 mmHg) and prolonged duration (>6 sec). LES can have normal or elevated resting LES pressures, similar to achalasia. CP is the primary symptom. Dysphagia is also seen Systemic sclerosis (scleroderma) is characterized by aperistalsis of low amplitude distal esophageal contractions and absent or low LES pressure. Up to 90% of patients with systmic sclerosis have esophageal involvement. This disease involves the smooth muscle layer, resulting in atrophy and sclerosis leading to the poor contractile/aperistalsis of the esophagus. These changes can lead to symp of heartburn and progressive dysphagia. These patients are at risk for reflux and subsequent stricture formation. GERD can cause esophageal injury and motility changes, thus changes assoc with GERD are considered seocndary esophageal motility disorders

Answer 271

1. B 2. A 3. C Hepatic adenomas are benign tumors occurring in women who take of have taken OCPs. Most common complication is bleeding secondary to rupture of large tumors. Many are found when patients have imaging to r/o gallbladder disease. Some evidence that incidence of HCC is incr slightly in these patients. Important to distinguish from FNH which are benign liver lesions that do not requires resection. Hepatic adenomas <4cm can be watched after OCPs are stopped. If they regress, they can be safely watched. Pregnancy predisposes to rupture, in patients who want to become pregnant, resection is mandatory. All lesions >4cm should be resected, if it can be done safely. RFA has been usued sporadically for pts who refuse sx and have multiple lesions but it is not considered 1st line Incidence of HCC is increasing b/c of incr incidence of Hep C. 80% of pts with HCC have either frank cirrhosis or fibrosis and inflamm. Prognosis and tx depend on both the extent of tumor and the extent of liver disease. Survival of pts with small tumors <2 cm is good regardless of tx. Conversely in pts with large tumors and decompensated liver function, medial survival rates are 3-6 months regardless of tx; therefore palliative care is the best option. In patients with <2 cm, RFA is the preferred tx unless patients liver disease is advanced enough to qualify for transplant. Pts with larger lesions who are candidates for resection should be resected. Patients with larger lesions who have more advanced liver disease should undergo either RFA or some form of arterial chemoembolization. Lesions 2-5 cm are most amenable to RFA. Lesions >5 cm have high local recurrence rates with RFA. Chemoembolixation is best for tumors 5-7 cm or patients with smaller tumors not amenable to RFA or surgery. Fpr chemoembolization, patients cannot have advanced liver disease. A bili >3 or significant ascites is a relative contraindication. Results for transplant are best for single tumors <5cm or 3 or fewer tumors <3cm.

Answer 272

1. C 2. B 3. A 4. D Insulinomas are most common type of functional PNET. Present with symp of hypoglycemia after fasting or exercise, a blood glucose < 45 when symptomatic and symp relieved by IV or oral glucose. This constellation of symp is named after Whipple and designated the Whipple triad. Vast majority of insulinomas are benign Gastrinomas are the second most common type of functional PNET. Majority are malignant at presentation, usually multicentric and located in the gastrinoma triangle. Oversecretion of gastrin leads to formation of ulcers. Glucagonaoms are rare PNETs. Present with four Ds: diabetes, dermatitis, DVT and depression. Rash is pathognomonic and is called necrolytic migratory erythema. Occurs in 70% of patients at dx and commonly predates other systemic symptoms Somatostatinomas are also rare PNETs that are usually very large at presentation. Commonly pts have gallstones caused by cholestasis VIPomas cause the watery diarrhea assoc with hypokalemia and achlorhydria

Answer 273

1. C 2. A 3. C Slef expanding plastic stents or fully covered self expanding metal stents can be used to cover perfs in the GI tract in select situations. Fully covered stents can exclude the area of perf and are easier to remove b/c the lack of tissue ingrowth, although migration rates are more problematic. In carefully selected pts, covered stents can be safely used to exclude small perforations or contained perforations, especially if leak is identified early. Undrained fluid or abscess that is excluded by the stent might require additional drainage procedures. Uncovered metal stents can be used for obstructing esophageal, duodenal or colonic cancers b/c they can relieve obstruction and palliate symtpoms. They have fewer problems with migration but are much more difficult to remove.

Answer 274

E in answer key Success rates of non op mgmt in many series are consistently >60%. Emoblization og splenic artery for CT detected pseudoanerysm or arterial blush has incr splenic salvage. Investigations in these patients have confirmed maintenance of immune fcn after embolizaion. Documented healing occurs earlier with grade I and II injuries more than severe injuries, there is no evidence thatn there is any specific variance in healing rate other than the more extensive injury suggests longer times to healing. Age >55 was once a criterion to exclude non operative mgmt of splenic injry for fear of incr non op failure rate. Age alone should not be a criterim used to exclude a patient from non op mgmt

Answer 275

A IO infusions has emerged as an excellent secondary venous access site in trauma resusc. Although the proximal tibia is commonly considered for the establishment of IO access, the sternum is a better alternative. Its thinner cortex and abundant red marrow and proximity to central circulation in some circumstances make it a better choice. Medicine delivery rates to central circulation are similar with IO and peripheral infusions, even in the setting of CPR. Infusion rates of colloid, including PRBCs, can achieve 2/3rds the rates seen with crystalloid infusions, indicating that the IO approach can be reliably used. Serum electrolytes, blood gases (similar to VBG) and blood for typing and crossmatching can be obtained with a slow pull of neg pressure from IO access. Infection rates are <1%

Answer 276

E Patient is comatose but now in shock. Non op mgmt of the hemodynamically normal patient with splenic injury is appropriate. In the presence of shock and severe assoc injuries, non op mgmt of a significant splenic injury is contraindicated. In addition, ongoing or delayed splenic bleeding may produce secondary brain injury. The next best step in management of this patient is laparotomy. Hypertonic saline is used in the setting of head trauma to raise the serum sodium and reduce cerebral edema. Similarly, hypothermia can be useful in mitigating the effects of neurologic injury. The major risk to this patient is the ongoing showck will worsen the neuro injury. Transfusion of 2 u of PRBCs and serial hematocrits would be indicated in the nonop mgmt of splenic trauma but is not appropriate in this pt who required immediate OR. Splenic angio and embolization is an option only for patients who otherwise are candidates for nonop mgmt. Splenic artery embolization at the time of angio is not assoc with a higher success rate of non op mgmt.

Answer 277

D-- worst answer options ever!!! Hypotensive after trauma likely secondary to hemorrhagic shock. Too unstable for CT scans. Diagnostic priority is to identify the source of bleeding. B/C FAST is equivocal and too hypotensive for CT, abdomen must be ruled out as a source for hemorrhage through DPL. Due to pelvic fracture, the RP hematoma can extend anteriorly, which can lead to false positive infraumbilical DPL through sampling of this anterior retroperitoneal blood. Therefore, in this setting a supraumbilical approach is warranted. N CXR does not absolutely rule out thoracic ao injury, even if the patient had such an injury, it would not likely be the cause of her hypotension, b/c these injuries are contained mediastinal hematomas. If they are not contained, the patients die at the scene or en route to hospital from rapid exsanguination.

Answer 278

B Pt demonstrates lateralizing signs of intracranial injury--blown pupil with inability to move contralateral side. Signs indicated imminent herniation b/c of compression of the L brainstem is resulting in inability to move the R side with pressure on the L optic nerve producing blown pupil. If efforts are not taken to reduce ICP immediatedly while getting the patient to the OR for cerebral decompression, his herniation will soon be complete and irreversible. In the acute setting it is acceptable to hyperventilate such patients as a way of gaining time to go to CT and the OR. Hyperventilation decr CO2, which leads to cerebral vasoconstriction and thus a drop in ICP. In addition, b/c there are no signs of hemorrhagic shock or hypotension from other causes, mannitol is safe to give in this setting to reduce cerebral edema and ICP. The Cushing reflex include bradycardia and hypertension in response to elevated ICP. The resultant HTN combats the elevated ICP to maintain cerebral blood flow.

Answer 279

C Retained traumatic HTX can occur in 5-30% after placement of initial chest tube. Main risk of leaving a retained HTX in situ is progression to fibrothorax which traps the lung or becomes secondarily infected leading to empyema. Several approaches incl placing a second chest tube, fibrinolytics, and surgical evacuation. VATS is the most effective means and is assoc with shorter length of stay. Fibrinolytic are widely used in peds, their success is not well established in adults. Rate of success of VATS without need to convert to open thoracotomy is also correlated with early intervention. As the HTX progresses to fobrothorax or empyema, ability to achieve lung release and evacuation of fluid diminishes b/c of the inflammatory response. Majority of HTX are evacuated within 3-4 days, patients who are still having moderate chest tube output beyond that time point should be investigated for retained HTX and if present, undergo a VATS bc their continued output is most likely the result of persistent clot within the chest.

Answer 280

A in answer key but some ppl advocate for B then A Lateral compression # with vertical shear is an unstable # pattern. Risk of arterial hemorrhage is higher than patients with a stable fracture pattern. In hypotenive pts, unresponsive to initial resusc with an unstable fracture pattern, pelvic angio demonstrate a significant arterial hemorrhage in 60-75% of cases. The neg FAST excludes the abdomen as a primary source of hemorrhage with a sensitivity of 80-100% in the setting of pelvic #, thereofre exp lap is not indicated. Use of DPL in the setting of a nonresponder to resusc should be considered if the FAST is equivocal or adequate views cannot be obtained. Use of ex fix requires that expertise be available to reduce this complicated #. Typically ex fix is useful to stabilize an open book pelvic #. Presence of gross blood in the urine indicates GU trauma. Most bladder injuries assoc with pelvic # are extraperitoneal and can be managed with a Foley catheter alone; therefore fross hematuria is not an indication for exp lap.

Answer 281

C Several RF have been assoc with an incr risk of intra abdo infectious complication in the setting of colorectal penetrating trauma--penetrating abdo trauma index, degree of contam, shock, number of units of PRBC given. This patient does not have any RF, so there is no need for diversion. There is incr evidence that even in the presence of shock, diversion does not reduce the risk of intra abdominal infectious complications and colorectal morbidity or mortality. These injuries are primarily repaired without diversion, as long as damage control laparotomy is nor required b/c of severe physiologic derangement. Next part of assessment requires determination of whether this is a destructive injury requiring resection and primary anastomosis vs debridement of the wounds and primary repair. B/C this is a small calibre pair of wounds, debridement and primary repair is acceptable unless the resultant repair results in a reduction of the circumference by >50% in which case resection and anastomosis should be performed. The placement of drains does not reduce abscess occurrence

Answer 282

D Although this patient has a normal GCS , he does have cervical spine tenderness on exam and imaging of the C spine is therefore indicated. Studies show that as many as 70% of pts initially evaluated with plain Xrays will eventually undergo CT scanning to complete assessment of the C-spine. CT scanning of the C spine is more accurate and less time consuming than plain C-spine films. For these reasons, CT scan without contrast is preferred over plain X-ray imaging of the C-spine in trauma patients. MRI is time consuming, expensive and inappropriate in this scenario.

Answer 283

D Bile leak from hepatobiliary tract injury is general dx by high external bilious drainage output, HIDA scan or CT. External drainage of suspected bilous fluid collection can usually be established with contemporary perc interventional techniques. To reduce the clinical impact of bile leak, establishing internal drainage of the hepatobiliary tree is a clinically attractive option given that the significant morbidity and mortality assoc with operative re-exploration. Recent case series document success with early ERCP with sphincterotomy and stent placement in the mgmt of bile leaks after both blunt and penetrating hepatic injury. It i dx and therapeutic in bile leak mgmt through ID of the injury site(s) and reducing the pressure gradient between the bile duct and duodenum.

Answer 284

D Triad of abdo pain, GI bleed and anemia in a pt with a hx of RUQ trauma, either blunt of penetrating, should raise the suspicion of hemobilia regardless of wheterh or not the pt reqd surgical intervention during tx of initial injury. Angiography is the only option that will both dx and tx by angiographic embolization of the pseudoaneurysm. EGD will identify the hemobilia visually but is of little other diagnostic use. Similar to colonoscopy, the age of this pt and lack of other comorbidities make endoscopic exam of the remainder of the GI tract for other sources of bleeding unnecessary. MRCP will likely identify the pseudoaneurysm and the connection to the biliary tree but will not allow tx.

Answer 285

A Optimal hemodynamic targets called permissive hypotension have yet to be determined but most would suggest a SBP of 60 is too low. Patients with TBI are not candidates for this approach Patients in hemorrhagic shock receive both plasma and platelets early in the resusc. Due to presence of acute traumatic coagulopathy in at least 30% of these patients on admission, waiting for the labs delays transfusion of needed coagulation factors. Thromboelastography shows promise as a guide to resusc in these patients b/c it is a point of care functional test of the pt's current coagulation status. Based on both military and civilian data, a ratio of 1 unti of plasma and platelets for every 1 or 2 units of PRBCs appear to provide the greatest survival benefit for pts requiring massive transfusion.

Answer 286

E Rib #s cause significant pain, both acutely and often long after d/c. Aggressive pain control--with PO, IV and epidural analgesia--improve outcome in patients with rib #s primarily bc of the decr in pneumonia Concept of rib stabilization has returned, using both minimally invasive techniques and open thoracotomy with a variety of systems. Anecdotal experience related dec time on the ventilator, improved pulmonary function, decr pain amd improved QOL. Unfortunately, the only outcome consistently demonstrated with a more invasive approach than aggressive pain control is an improvement in the chest wall deformity that does not result in any functional or quality of life improvement.

Answer 287

B RP hematomas are classified into 3 zones: central zone (zone 1), lateral (zone 2), and pelvic (zone 3). Patient has a zone 1 central RP hematoma. In the supramesocolic location, the suprarenal abdominal aorta, celiac axis, prox SMA and prox SMV and proximal renal artery may be injured. In the inframesocolic position, the infrarenal abdominal aorta, and infrahepatic IVC may be injured. The optimal surgical exposure for an expanding zone I central hematoma extending toward the L RP is via use of a L sided medial visceral rotation. With this dissection, the spleen, stomach, tail of panc and L kidney are swept toward the midline and onto the R side of the patient, allowing for proximal and distal control of the aorta and its branches through digital pressure or vascular clamp

Answer 288

B Antiplatelet therapy has become a cornerstone for CV and neurovasc medicine, with many pt on chronic plavix. In patients with significant bleeding related to plavix use, potential antiplatelet reversal therapies include platelet transfusion, desmopressive, and recombinant factor VIIa, all of which have potential associated complications. Transfusion of platelets remains the current proposed therapy for patients on plavix and traumatic hemorrhage, although its clinical utility has yet to be firmly estblished. USFDA has approved a test for assessing P2Y12 mediated platelet function that measures the degree of platelet inhibition from the use of P2Y12 inhibition drug therapies known as thienopyridines (including plavix, prasugel, ticlopidine and ticagrelor). Test results are reported as perecntage inhibition. Higher % inhibition indicates greater antiplatelet effect. Before elective surgery, d/c antiplateley and test to confirm <20% platelet inhibition.

Answer 289

B Bleeding from the liver not controlled by packing alone suggests a complex hepatic injury requiring its orderly assessment. 1st step entails a Pringle maneuver, with placement of a vascular clamp on the porta hepatis to control portal vein and hepatic artery bleeding. Topical hemostatic agents are indicated only for minor hepatic bleeding. Selective hepatic vessel ligation, placement of deep parenchymal sutures, or elective hepatic artery ligation are strategies considered after the Pringle maneuver has been completed. After the Pringle maneuver has been applied, actively bleeding and injured bile ducts should be ligated. Although not performed as often with the increased used of packing, finger fracture of the hepatic parenchyma can aid this endeavor. Placement of deep parenchymal sutures to obtain hemostasis is also an option, although there is the risk of tissue necrosis or injury to intact vessels and bile ducts. If bleeding persists despite these maneuvers, hepatic artery ligation can be considered. This maneuver poses a risk of liver necrosis, particularly when accompanied by the placement of deep liver sutures or the overzealous use of packing. It should be performed judiciously. Post op angioembolization is a better option when available. If significant bleeding persists after a Pringle maneuver, juxtahepatic venous injury to the retrohepatic IVC or major hepatic veins must be suspected. Every effort must be madeto control bleeding by packing. If this is not possible, additional options of vascular isolation with venovenous bypass or used of stent grafts should be considered.

Answer 290

C Posterior dislocation of knee can result in significant injury to the popliteal artery. Thrombosis with distal limb ischemia is the most common presentation of popliteal artery injury. Most patients with occlusion of the popliteal artery have ischemia of the calf and foot. Alternatively, disclocation of the knee followed by spontaneous reduction may result in a shear effect, producing and intimal injury that results in delayed thrombosis. Concomitant venous and neurologic trauma make these injuries extremely morbid. Once a popliteal artery injury has been dx, urgent operative repair with open exploration of the popliteal artery is indicated. Typically there is extensive disruption of the intima and often there is full thickness involvment of the arterial wall. For repair of blunt injuries to the popliteal artery, both groins and lower extremities should be prepped and draped. Contralateral saphenous vein is the conduit of choice for bypass and should be readily accessible. Injury is best and most commonly approached through a medial incision extending from the posterior margin of the femur to the posterior margin of the tibia. Prox arter is located at its exit from the abductor canal. Division of the medial head of the gastrocnemius and semitendinosus muscle is required to expose the area behind the knee. Care should be taken to avoid lacerating the saphenous vein. Posttraumatic deep vein insufficiency is common and this superficial vein may become an important collateral. An incision along the posterior margin of the tibia helps expose the distal popliteal artery . A posterior approach using an S shaped incision has also been described. This approach is faster and requires a less extensive dissection but provides more limited access to the prox and distal popliteal injury. Injuries requiring some debridement of the artery but without significant loss of the original length of the artery can be repaired via tension free end to end anastomosis. Usually however, repair of blunt injury to the popliteal artery requires careful debridement of all injured vessel wall and rension free repair with saphenous vein interposition. Four compartment fasciotomy of the calf should be performed only if there is a suspicion of a compartment syndrome after repair of the popliteal artery or if a concomitant venous injury is present

Answer 291

A Small bowel injury occurs in 1% of blunt abdo traum patient. Incidence of missed injuries is higher now than in the past. This is b/c peritoneal lavage is not used very often and patients with splenic and hepatic injuries are often times watched. Patients with OR delayed >24 hrs have incr mortality Certain CT or physical findings make a small bowel injury more likely. Chance #s (L2) are assoc with a 52% occurrence of small bowel injuries. FF in the abdomen, without assoc spleen or liver injuries, is also assoc with small bowel injuries. A patient with an abdo seat belt sign has an increased incidence of small bowel injuries. In this patient, physical exam is unreliable b/c she in unconscious. Serial FAST is not indicated for follow up of FF Abdo CT with enteral contrast may show extravasation but is not always diagnostic. Mesenteric injuries, which ultimately will lead to bowel necrosis, are not more liekly to be picked up with enteral contrast.

Answer 292

C Rupture of the diaphragm should always be considered in a patient whose mechanism of injury involves significant deceleration. Given the amt of force required to rupture the diaphragm, there is a high likelihood of co-existing injuries, particularly to the abdominal viscera. Herniation of abdominal contents into the chest implies the presence of a complex laceration of the diaphragm with at least moderate tissue loss. Stomach, spleen, colon, omentum, and small bowel may all herniate into the thorax High likelihood of coexitent injury to abdominal viscera and the need for reconstruction of the diaphragm mandate laparotomy. At the time of the OR, the herniated viscera need to be relocated within the abdomen. After reduction of the viscera into the abdomen, a careful inspection of all of the contents of the abdomen should be performed and any injuries should be repaired. After this has been accomplished, a full inspection and visualization of the diaphragm should be performed. The R hemidiaphragm is best inspected after transection of the falciform and gentle downward traction of the liver. The L hemidiaphragm can be visualized by applying gentle downward retraction of the spleen and lesser curve of the stomach. A chest tube should be placed in the 5th ICS at the mid axillary line before definitive closure of the diaphragm. Smaller injuries may be repaired primarily whereas larger injuries with significant loss of diaphragmatic tissue will require placement of a patch to repair the defect. The goal is a tension free repair to reduce the likelihood of a recurrent diaphragmatic hernia.

Answer 293

C Transection of the body of the pancreas with a hematoma is a grade 3 injury. Needs to be tx to prevent pancreatic fistulas and ascites. Definitive tx is distal pancreatectomy. In a stable pt, this can be acheived with splenic preservation Grade 1 and 2 injuries can often be treated with observation, bowel rest and drainage. Grade 4 lesion with transection of the R of the SMV is more problematic. This may require preservation of the distal portion of the pancreas and drainage with a Roux en Y limb. This is a rare injury and endocrine pancreas function is generally preserved if 20% of the pancreas is left intact. Grade 5 injuries assoc with significant duodenal injuries may require a Whipple Observation would not be appropriate for this injury b/c the risk of panc fistula would be prohibitive. The most common complication of this injury, even with proper treatment is pancreatic fistula (7-20% of high grade pancreatic injuries). The fistulas are divided into low (200cc/day) and high (>200cc/day) output. Most low grade fistulas will resolve with drainage. Higher output fistulas and those that persis for >2 week may require studies to identify the exact source of the prolonged leak and may require operative mgmt

Answer 294

C Tx of penetrating wounds of the esophagus depends on the anatomic location of the injury. H&p and endoscopy indicated a thoracic esophageal injury in the R chest. These injuries are best tx with primary repair in 2 layers and then buttressed with a local muscle flap. In more severe injuries, short (<2 cm) circumferential resection and anastomosis can be performed, althought this degree of injury is much more rare. Devastating injury can be managed with a T tube placement into the esophagus. This management is usually reserved for extremely hemodynamically unstable patients with other injuries. Alternatively, ligation of the esophagus is possible with a proximal cervical esophagostomy, but this is much less preferred and requires major reconstruction. In all repairs, the mediastinum should be widely opened and irrigated, and drainage tubes should be placed. Chest tube drainage and abx would be inadequate to control the fistula and would have a higher mortality and complication rate than immediate repair. Cervical esophagostomy would not be indicated b/c primary repair is preferred in this injury. Cervical esophagostomy is reserved for massive or multiple perforations with an inability to reconstruct. Endoscopic stent placement is not well described in the trauma setting. Transhiatal repair with G tube placement would be reserved for a lower esophageal injury, approached via the abdomen

Answer 295

C In a recent report 75% of patients transferred had CT imaging before transfer. 58% required repeat imaging b/c of failure to send the scan with the patient, software incompatibility, inadequate technique, or the additional clinical indications to repeat the scan (>2 hr delay in transfer of severely head injured patients). Added costs are also documented for repeat formal reading of the CT by the receiving facility's radiologist.

Answer 296

E In a series of pts with penetrating abdo trauma, a surgical site infection occurred in <5% of patients with an isolated colon injury. A concomitant gastric injury increased the SSI rate to 30%. No RCT has compared colonic anastomosis to stoma formation in the setting of colonic injury requiring delayed abdominal closure. Patient factors, time to closure and location of colonic injury may affect the decision to perform a primary anastomosis compared with colostomy. No difference in rate of abscess formation with either strategy. Anastomosis recomended whenever possible. Prolonged used of Abx beyond the periop period has not influenced the rate of soft tissue infection.

Answer 297

D Blunt popliteal artery injurys most commonly occur after posterior dislocation of the knee, a high index of suspicion is critical, b/c these injuries may be clinically occult. Before definitive vascular exam, bony #s or knee dislocations should be realigned. Findings on physical exam are classified as hard of soft signs of vascular injury Hard signs include pulsaline hemorrhage, significant blood loss, absent distal pulses and acute ischemia Soft signs include proximity to vasculature, significant hematoma/small hemorrhage, and arterial pressure index <90 In general, hard signs constitute indications for operative exploration or on table angiography; this patient has no hard signs of vascular injury. Measurement of the arterial pressure index (API) comparing the SBP in the affected extremity with an upper extremity should be performed in all pts with dislocations or fractures. API compares the arterial pressure, detected by Doppler and a blood pressure cuff applied proximal to the injury, in the injured extremity to the contralateral uninjured extremity. API should be performed in all patients with dislocations or fractures. API <0.9, a CT Angio or catheter based angiogram is indicated.

Answer 298

D Occult thoracic vascular injury must be diligently pursued b/c of the high mortality of a missed lesion. Approx 10% of deaths after MVC are due to blunt descending thoracic aorta tears. Blunt injuries are typically located in the proximal descending aorta just beyond the subclavian artery at the ligamentum arteriosum. Due to shear forces, there is typically partial transection of the aorta with pleural containment preventing exsanguination. Occasionally complete transection or intimal dissection of the aorta with false lumen extension occurs. Suggestive findings on CXR include mediastinal widening, loss of aortic knob, apical capping, blurring of the aortopulmonary window, deviation of the trachea, and depression of the L main stem bronchus. As many as 7% of patients with a blunt desc aortic injury have a normal CXR. Therefore screening helical CTA is performed based on the mechanism of injury. Desc thoracic aortic injuries may require urgent if not emergent intervention. To prevent aortic rupture, pharmacologic therapy with an esmolol infusion should be instituted with a foal SBP of <100 and HR <100. IV beta blockade dec the shear stress of the aortic wall. Use of an agent with a short half life permits safer titration in the multiply injured patient. In this pt with radiographic findings consistent with a desc aortic injury, esmolol should be started before transport. At the receiving hospital, definitive dx of the injury can be performed.

Answer 299

A Patients with blunt cardiac injury typically present with tachycardia or rhythm disturbances but occasionally with cardiogenic shock or cardiac tamponade due to atrial or R ventricular rupture. There is no gold standard to identify blunt cardiac injury. An EKG should be performed in all patients with suspected blunt cardiac injury to evaluate for persistent tachycardia, arrhythmia, ST segment changes, ischemia and heart block. However, there are not pathognomonic EKG findings. Patients with a high clinical suspicion for cardiac contusion who are hemodynamically stable should be monitored for 24 hrs for dysrhythmias by telemetry. Patients with abN EKG results should be admitted for continuous monitoring. Patients with hemodynamic instability should undergo echo to evaluate for wall motion abN, valvular dysfcn, chordae rupture, pericardial fluid or diminished EF. Troponin levels should not be routinely monitored; cardiac enzyme determination does no correlated with the risk of cardiac complications in patients with blunt cardiac injury. In the patient with concern for acute MI, a troponin level should be checked.

Answer 300

E Extraction from burning building suggests a high likelihood of an assoc inhalation injury, which requires early initiation of high flow oxygen An estimation of TBSA to include full (third degree) and deep partial (second degree) burn injuries serves as a guide to fluid requirements. Parkland formula recommendes 4cc/kg/%TBSA over the first 24 hrs (first half is given over 8 hrs and the remaining over 16 hrs, only areas covered by 2nd degree burns is given consideration). Recent evidence suggests that large volume resuscitation is assoc with incr risks of infectious complications, ARDS, and death. Therefore fluid resusc should be titrated to clinical endpoints to include hemodynamic parameters and UO 30-50 cc/hr in adults and 0.5-1.0 cc/kg/hr in children

Answer 301

E Primary repair of colon injuries include suture repair or resection of the damaged segment with reconstruction with ileocolostomy or colocolostomy. Colostomy is still appropriate in a few patients but the current dilemma is how to select which patients should undergo the procedure. Advantage of definitive tx must be balanced against the possibility of anastomotic leak if suture lines are created in suboptimal conditions. Currently, the overall physiologic status of the patient directs decision making rather than local factors. This patient is presenting in a delayed fashion from his injury and has developed peritonitis. In addition, he is showing physiologic compromise based on his vital signs and base deficit. Primary repair of the injury is not indicated. Damage control surgery is indicated in those patients who are intraop dying from the bloody viscious cycle of coagulopathy, hypothermia and metabolic acidosis. Once the cycle stats, each component magnifies the other, leading to a downward spiral and ultimately a fatal arrhythmia. The purpose is to limit operative time, permitting the pt to return to the SICU for physiologic restoration, hence breaking the cycle. Indications to limit the initial operation and institute damage control surgery include temp <35, arterial pH <7.2, base deficit <15 or <6 in pts >55, and INR >50% of normal. Colon injuries may be controlled with rapid suture approximation or the injured segment can be excised using a GIA stapler, leaving the bowel in discontinuity. After adequate resusc, patient is taken back to the OR for repair or diversion. Patients requiring damage control with devastating colon injuries or those with an obviously compromised vascular supply to the colon are clearly candidates for temporary colostomy. Colocolostomy with diverting loop ileostomy may also be considered for these high risk patients.

Answer 302

E in answer key but realistically you would do things simultaneously and you need to improve the patient's hypotension Patient with SBP of 75 and evidence of a SCI (lack of tachycardia, motor deficits, priapism), most likely etiology of the hypotension is neurogenic shock. #s of cervical spine or high thoracic vertebrae can result in neurogenic shock caused by disruption of the sympathetic regulation of the peripheral vasculature. However, this is a dx of exclusion and other sources of hypotension including active hemorrhage, must be excluded. Life threatening injuries that must be excluded are massive HTX, tension PTX, cardiac tamponade, massive hemoperitoneum, and unstable pelvice #. Three critical tools to identify and differentiate these in the multisystem trauma patient are CXR, pelvic XR, and FAST. Normal CXR and pelvis xr exclude a HTX, PTX, or pelvic # causing the patient's hemodynamic compromise. FAST exam should be performed to exclude cardiac tamponade or intraabdominal hemorrhage as the source of the pt's hypotension. If the FAST is neg, vasoactive agents are the tx of choice for this pt's persistent shock despite crystalloid administration. Typically beta agonists (dopamine) are used before the addition of an alpha agonit to incr the patient's MAP. Although imaging is indicated in this patient, transport of a hypotensive pt out of the ER for CT or MRI may be hazardous; monitoring is compromised and the environment is suboptimal to deal with acute problems. Establishing adequate perfusion in this patient before transport for imaging is warranted.

Answer 303

C The young burn victim will require significant investment of resources adn staff, but who may sufficiently benefit from aggressive resusc to warrant reassessment of her likelihood of survival over the next 28-72 hrs

Answer 304

E. In real life we don't screen for A Although rare after blunt trauma, CVI can have devastating consequences if improperly tx. Screening of blunt trauma pts with high energy transfer at risk is necessary to identify injuries before symtpoms occur. Mandibular #, Lefort II or any midface #, basilar skull # and prox C1 through C3 #s all have significant correlation with the incidence of blunt CVI. Injuries such as significant thoracic trauma and severe closed head injury also have an incr assoc with blunt CVI. Distal cervical injuries without transverse foramen involvement or spinous process #s have no correlation with an incr risk of CVI

Answer 305

B Pt most likely has a TBI. CT scan and most likely a neuro procedure will be necessary. Regardless, ABCs of trauma take priority to maximize survival and preinjury status of the patient according to ATLS. Initial tx of severely injured patient consists of primary survey, initial resusc, secondary survey, diagnostic imaging, and finally definitive tx. With head injury, survival is adversely affected by hypotension and poor oxygenation. Although the CT scan may be important, it is not part of the primary survey.

Answer 306

C The renal artery is an end artery and there is no collateral circulation in the kidney. Therefore, acute ligation of the artery will cause infarction of the kidney. Of note, in a patient with multiple renal arteries, ligation of 1 of the arteries will cause infarction of that portion of the kidney. Acute ligation of the SMV has effects on both the liver and the small intestine. Even if the liver survives, the small intestine usually does not. The only way this would not be true would be in the unlikely situation that the patient has portal HTN and collateral circulation vai well developed varices. Acute ligation of the SMA also will cause acute infarction of the small intestine, unless significant collaterals developed from an already disease artery. Patients with acute common femoral ligation also will develop acute leg ischemia. Ligation of the renal vein near the vena cava is safe fo r the L kidney. It may be intentionally ligated in a open AAA repairs. The L renal vein may even be used as a graft in complicatied PV reconstruction. The gonadal vein, lumbar vein and adrenal vein all enter the renal vein closer to the hilum and can drain the kidney. In the R kidney, all those tributaries drain directly into the vena cava, therefore the R renal vein cannot be ligated

Answer 307

A Immediate temporary stabilization with "sheeting" of the pelvis or application of commercially available pelvic binders should be performed. More definitive stabilization is obtained with placement of an external fixator. Pelvic binders and external fixation decr pelvic volume, which promotes tamponade of venous bleeding and prevents secondary hemorrhage from the shifting of bony elements. Additional options for pelvic hemorrhage control cause by fracture related bleeding. Pelvic angioembolization is an effective means of controlling hemorrhage from branches of the internal iliac vessel. Angioembolization does not address venous of bony hemorrhage within the pelvic that can comprie up to 85% of bleeding observed in complex pelvic #s. Preperitoneal pelvic packing can be used to adress pelvic #s-related hemorrhage. This technique which involves placing laparotomy pads into the pelvic space through a suprapubic, preperitoneal incision, addresses the venous and bony source of hemorrhage through direct tamponade. Pelvic packing may also be used as a temporizing measure in patient with arterial bleeding. Patients with persistent transfusion requirements after pelvic packing (>4 units of PRBCS within 12 hrs of OR in a noncoagulopathic patient) should undergo diagnostic angiography; selective angioembolization is performed if contrast extravasation is identified.

Answer 308

E FAST is an ultrasonic eval of the pericardial sca and abdomen looking for abnormal fluid that has accumulated in the dependent areas of the pericardium and peritoneal cavity. Four views are required for a complete FAST exam: pericardial, R upper quadrant, L upper quadrant and bladder. FAST exam will detect significant abN amts of fluid. It will not identify which organ has been injured and it does not adequately evaluate the RP Surgeon performed US can be 83% sensitive and 99% specific in trauma patients with truncal injuries and 100 sensitive and specific for hypotensive patients with blunt abdominal trauma. However the FAST exam still suffers from operator dependence and operator error. FAST will be positive in the RUQ view if 100-250 cc of fluid is present. In a patient in class IV shok with a hx of blunt abdominal trauma, a neg FAST should not deter the surgeon from taking the pt to the OR for exploration. The specificity for the FAST exam has always been better than the sensitivity; the study can be neg and no fluid may be found, yet the patient may still have a ruptured spleen. If pt with a positive of equivocal FAST result remains hemodynamically abN, the physician should not repeat the US assessment but go directly to the OR for abdominal exploration.

Answer 309

D Penetrating injury to the neck can cause injury to the vasculature or aerodigestive tract. Neck is divided into three zones. Zone 1 extends from the thoracic inlet to the cricoid cartilage. Zone 2 extends from the cricoid cartilage to the angle of the mandible. Zone 3 extends from the angle of the mandible to the base of the skull. Patients with hard signs of injury (pulsatile bleeding, an expanding hematoma, and obvious aerodigestive tran injury) should go immediately to the OR. If hard signs are not present, patients with zone I and 3 injuries should have a CT angiogram performed. Some controversy may exist in the management of stable zone 2 wound that penetrate the platysma muscle. Routine neck exploration was once advocated and can still be performed however the high rate of neg exploration and advances in CTA have led to a selective mgmt approach. If the wound penetrates the platysma, further specific evaluation should be performed. Neck CTA will reveal vascular injuries as well as significant aerodigestive tract injuries when other test and physical exam are neg. Physical exam and close observation is a possible option in select centeres that can provide close observation and serial exams but only in patients with no clinical signs of vascular or aerodigestive tract injuries

Answer 310

A Dabigitran is a PO direct thrombin inhibitor that works by binding to the active site of the thrombin molecule. It is eliminated 80% through renal mechanisms and 20% through hepatic conjugation and excretion into bile. Peak effect is 2-3 hrs after ingestion and half life is 14-17 hrs in pts with N renal function. Dabigatran should not be used in patients with renal failure and should be dose adjusted in renal insufficiency. Also contraindicated in patients with hepatic failure. Does not interact with cytochrome P450 so does not have the multiple drug interactions of warfarin and has no food interactions. Its action is mediated through P glycoprotein and drugs that inhibit this system such as amiodarone, verapamil, quinidine, and clarithyromycin should be used with caution b/c they increase dabigitran's duration and effect. Activated partial thromboplastin time and thrombin clotting time are the best measures of dabigitran anticoagulation. Normal values indicate little to no anticoagulation effect of dabigitran. Prothrombin time and INR are not reliably affected. When elective sx is planned, dabigitran should be held for 24 hrs before procedures with a low or standard risk of bleeding. When there is a high risk of bleeding, dabigitran should be held for 2-4 days. In pts with any degree of renal insufficiency, these times are prolonged based on the CrCl. In cases of severe or life threatening bleeding, reversal of dabigitran's activity can be acheived with hemodialysis or hemofiltration. Activated factor VII and prothrombin complex concentrates effectively reverse dabigitran anticoagulation activity in healthy volunteers and lab animals. Vit K, protamine, tranexamic acid, desmopressin, aprotinin, and amiocaproic acid are not expected to be effective. Plasma products such as FFP and cryoprecipitate will not replenish thrombin in great enough amts to have an effect on dabigitran

Answer 311

C Traditional apprach was to leave the cervical collar on until the pt could be clinically evaluated. Prolonged cervical spine immobilization causes pressure ulcers, airway problems, catheter related complications, failed enteral nutrition, and difficulty management elevated ICP. Debate persists about whether MRI is helpful in detecting clinically significant spinal instability in pts with a normal CT C-spine. MRI can identify many small cervical spine injuries missed by CT, there is debate about whether these identified injuries are significant ore require intervention. A study compared 2 groups of obtunded patients with N cervical spine CTs. First group was required to have a normal MRI before c-spine immobilization could be d/c'ed. The second group was required only to have a N cervical spinal CT to d/c the cervical collar. Pts in the CT group had a shorter duration of c-spine immobilization, required shorter periods of mechanical ventilation and had shorter ICU and hospital stays. EAST 2009 guidelines list the 3 options for obtunded patients with normal CT exams of the c-spine 1) continue cervical collar until clinical exam can be performed, 2) remove the cervical collar on the basis of CT alone, 3) remove the cervical collar on the basis of a N MRI. Guidelines recommend early cervical collar removal as advantageous.

Answer 312

D Major vasc injury of the extremity portends a risk of reperfusion injury leading to compartment syndrome. Dx of compartment syndrome should be based primarily on clinical exam and liberal used of 4 compartment fasciotomy should be employed to decr morbidity and mortality assoc with delayed or missed dx and management of compartment syndrome. In the awake pt, first sign is the presence of pain out of proportion to severity of extremity injury.If untx, paresthesia and paralysis may occur. Presence of tightness and tenderness on palp and pain on passive stretch of the involved compartment should alert to likely presence of compartment syndrome Measurement of compartment pressure is helpful as an adjunct to clinical exam but does not rule out presence of compartment syndrome. Compartment pressure of 30-45 mmHg or a compartment pressure within 30 mmHg of diastolic as cutoff for performance of fasciotomy; however there is no gold standard. Early dx and tx in high risk pts decr amputation rates. Factors leading to a high risk compartment syndrome incl prolonged ischemia, presence of shock, combined arteral and venous injury, popliteal vasc injury and massive soft tissue injury. Patients with these risk factors should be considered for early fasciotomy.

Answer 313

D Neurogenic shock refers to the syndrome of hypotension and bradycardia that can result from a spinal cord injury above T6 level. It is caused by interruption of the spinal sympathetic nervous system pathways. Resulting unopposed vagal tone causes bradycardia and peripheral vasodilation, reducing peripheral vascular resistance and leading to hypotension Dx of neurogenic shock is by means of clinical exam, and patients with spinal cord injury and neurogenic shock are noted to have peripheral vasodilation (i.e. pink, well perfused extremities) and brisk cap refill. This is in contradistinction to hypovolemic shock, in which there is hypotension accompanies by tachycardia, and extremities are pale and cool due to reflex vasoconstriction Initial tx of trauma pt with hypotension always includes volume resusc. This tx suffice for some pts with neurogenic shock. Not uncommonly low dose pressors are required to incr peripheral vasoconstriction, incr HR or both. Spinal shock refers to the decreases in reflex and muscle tone activity that occur after injru and are gradually replaced by hyperreflexia and spasticity. These chanes are often accompanied by changes in motor and sensory function

Answer 314

D Pts with penetrating wounds to abdo and eiher hemodynamic instability of peritoneal signs require urgent laparotomy. Over the last several decades, nonop mgmt of pts with anterior abdo stab wounds has become increasingly accepted. This selective mgmt requires N vitals, minimal abdo tenderness, and a pt who can be reliably examined (i.e. no brain injury, SCI, intoxication or need for sedation or anesthesia). Surgeons are less willing to attempt nonop mgmt in pts who have suffered GSWs to the abdo b/c of perceived and reported high incidence of intra-abdo injury. Unfortunately, nontherapeutic laparotmy has consequences as well incl SBO, PTX, ileus, wound infection, MI, visceral injury, and even death. Ventral hernia is also reported No clinically significant injuries in 1/3 with GSW to anterior abdo and approx 2/3s of pts with GSW to the back. Therefore, mgmt strategy incl mandatory laparotomy for the pts will result in significant incidence of nontherapeutic sx. EAST recommend that routine laparotomy is not indicated in hemodynamically N pts with abdo GSW if the wounds are tangential or in the RUQ and there are no peritoneal signs. CT Abdo/pelvis should be strongly considered as a dx tool to facilitate initial mgmy decision, and pts should be followed for 24 hrs with serial abdo exam performed by an experienced clinician. EAST recommends that a majority of pts with penetrating abdo trauma managed nonop can be d/c after 24 hrs of observation in the presence of a reliable abdo exam and minimal to no abdo tenderness and tolerating PO intake. Extreme caution should be exercised when attempting selective nonop mgmt of pts with penetrating abdo trauma.

Answer 315

D IO infusion is safe, quick and versatile in adults. IO Tibial and humeral placement is possible with similar flow rates when using pressure bags. Successful placement of IO is quicker and more reliable on first attempt than central venous catheter placement. When comparing first attempt placement failure, IO failed 15% of the time vs 40% of central venous catheter placement in setting or ER resusc. Presence of a # is a contraindication for placement of IO at that boney site due to risk of fluid extrav

Answer 316

B Compartment syndrome eventually causes ischemia and necrosis in the confined fascial compartment of a limb and can lead to significant disability or even limb loss. Dx of compartment syndrome in children may even be more challenging than in adults due to fear, lack of cooperation, ineffective communication, and the challenges of measuring compartment pressures at the bedside. Understanding the common risk factors for development of a compartment syndrome enhances the clinician's index of suspicion for this potentially devastating complication In adults, the more common risk factors for development of compartment syndrome include tibial diaphyseal #, soft tissue or crush injury, distal radius #, or radius and ulnar diaphyseal #. Review of children and adolescents with compartment syndrome found most were assoc with # (85%) or crush injuries (13%). Vascular injury after posterior knee disloction were uncommon injuries in children. Review showed that open #s significantly incr the risk for compartment syndroem, suggesting that fascial disruption from an open # does not adequately decompress the compartment. The incr energy reqd to cause an open injury presumably results in more extensive soft tissue damage and compartment swelling.

Answer 317

D RF incl major intra abdo sx or trauma, massive fluid resusc or transfusion, severe pancreatitis, ruptured AAA, and burns. Abdominal compartment syndrome = sustained intra abdominal pressure > 20 mmHg (with or without abdominal perfusion pressure <60 mm Hg) assoc with new organ dysfcn or failure Primary occurs most commonly after surgical procedures assoc with massive resusc. Secondary is due to medical condition such as ascites or conditions requires resuc without an abdo procedure. Pt here is high risk for developing primary abdominal compartment syndrome after massive transfusion with ongoing resusc. Ongoing resuc results in bowel edema and incr IAP and ultimately acute renal failure, hypoxemia and diff ventilating the pt. Albumin administration, neuromuscular blockafe, flluid restriction and diuretics are medical tx to reduce IAP in pts with secondary or recurrent abdo compartment syndrome.

Answer 318

C Hard signs of vascular injury include active hemorrhage, absent distal pulses, large pulsatile or expanding hematoma, distal ischemia, and bruit or thrill over the wound. Presence of hard signs mandates surgical evaluation and tx Soft signs of vascular injury include small hematoma, injury to related nerves, unexplained hypotension, hx of hemorrhage no longer present and proximity within 1 cm radius to underlying vessel. Doppler arterial pressure index (API) as a screening tool. Compares arterial pressure, detected by Doppler and a bp cuff applied proximal to the injury, in the injured extremity to the contralateral uninjured extremity. Signficant vasc injury can be excluded with a NPV of 99% when API > 0.90. If the API <0.90, further imaging with arteriography, or, more recently, CT angio is appropriate to r/o significant vasc injury

Answer 319

A In the Transfusion Requirements in Critical Care trial, a restrictive transfsuion strategy in which RBCS were transfused for a Hb <70 to maintain a Hb of 70-90 was found to be as effectve as a liberal transfusion strategy in which RBCs were transfused for a Hb <100 to maintain a Hb concentration of 100-120.

Answer 320

B ARDS and its less severe form acute lung injury (ALI) result in mortality rate as high as 40-50%. RF include traumatic injury, TRALI, sepsis, pneumonia, aspiration, and pancreatitis. In addition, ventilator induced lung injury may contribute to the development of alveolar injury by causing alveolar stretch as the result of large inspired tidal volumes, enhancing the inflammatory response. Limiting tidal volumes, and thus the ensuing inflammatory response may decr the incidence of ALI, ARDS and mutiorgan failure. Mortality is lowest in pts treated with 6mL/kg tidal volumes.

Answer 321

D After blunt trauma, number of rib #s correlates with mortality. May be direct effect of #s (pain, splinting, and subsequent pneumonia) or the rib #s may be a marker for the degree of underlying pulmonary injury. CXRs are obtained during the initial evaluation of trauma pts to assess the degree of injury. Incr use of CT has better documented the extent of injury and allowed correlation of initial CXR with outcomes. Any parenchymal injury or rib # identified on screening CXR was assoc with a sig incr in risk for subsequent pulmonary morbidity. Fracture location had no effect on resp failure, pneumonia, or mortality when they were confined to 1 anatomic location. Although CT scanning markedly improved the accurate detection of rib #s, initial CXR was a better predictor of subsequent pulm morbidity and mortality. The incidence of major vasc injury was similar in pts with or without first or second rib #.

Answer 322

E Presence of at least 3 rib #s is assoc with incr mortality and ICU length of stay, especially in the elderly. Pneumonia may occur in up to 1/3 of pts. Thus early mgmt focuses on pain control and adequate clearance of pulmonary secretions. No difference in mortality or hospital length of stay between epidural and IV opioids. Pneumonia was more common in the IV opioid groip. Failure to achieve adequate pain control was the same in both groups. Hypotension is more common with the use of thoracic epidural. Pain at rest during the initial 72 hrs was not significantly reduced by epidural analgesia

Answer 323

B Renal injuries are commonly graded by CT using the Kidney Injury Scale. Routine repeat imaging is often used to assess healing after either operative and nonoperative mgmt of trauma. Several studies have suggested that routine imaging may not be necessary in all pts. In patients who underwent routine follow up imaging after non op mgmt, rate of progression was 0.93%. In the pts reimaged due to a clinical indication, 20% had progression requiring a change in tx. Researchers concluded that routine reimaging in the absence of clear clinical indications has little benefit and changes mgmt in <1 %. In a study of pts with grade III and IV renal traum who had nonop mgmt, all pts had repeat scan at 36 hrs and 5 days. Progression of injury was found in 10% but all of them had other clinical findings including fever, hematoma or flank pain. Pts dx with kidney injury by CT were followed over a 3 yr period. Grades I, II, and III were grouped as low grade and Grade IV and V were grouped as high grade. No pt with a low grade injury managed non op, regardless of mechanism, developed a complication. Conversely, high grade injuries managed non op were assoc with a 10% (blunt) to 20% (penetrating) complication rate identified on follow up CT. All pts who developed complications were symptomatic, which prompted the imaging. All complications after a penetrating injury required intervention for the mgmt of the complication

Answer 324

E Common etiologies of non hernia associated chronic groin pain include osteitis pubis, athletic pubalgia, sports hernia, and adductor tendon pathology. Osteitis pubis is inflam at the level of the pubic symphysis. It can present with pain over the midportion of the pelvis but is occasionally assoc with pain in the groin and the inguinal region. Dx features incl tenderness on palp of the symphysis itself ad findings of inflamm on MRI scanning of the pelvis. No sx interventions for this entitiy. Mgmt consists of PT and anti inflam meds but occ surgical intervention with offloading of the pubic tubercle is required. For both osteitis pubis and athletic pubalgia, steroid injections can be used Sports hernia is not a true hernia. It is a weakness of the inguinal floor. Weakness typically develops in ppl who participate in significant physical activity of athletics. When the inguinal floor weakens and a bulge develops, pressure is placed on the genital branch of the genitofemoral nerve and can lead to chroinc groin pain. Pt will complain of hernia type pain in the groin and will often describe radiation into the testicle on the side of the symp. On exam, there may be tenderness with palp of the inguinal floor through the external ring, but a true hernia is not identified with Valsalva. B/c this is an anatomic defect similar to an inguinal hernia, steroid injections and PT may provide short term symptomatic relief but recurrence is common. Dx is made by hx but is often confirmed by U/S which shows weakness of the inguinal floor with Valsalva. Tx requires surgical intervention with reinforcement of the inguinal floor and often sacrifice of the genitofemoral nerve. Done lap or open.

Answer 325

E Trauma to extraperitoneal rectum is rare and is usually the result of penetrating injury. Injuries to the extraperitoneal rectum are not always obvious, and a high index of suspicioun should be exercised when the mechanism is compatible with such an injury. Initial eval includes DRE and rigid anoscopy/proctoscopy. DRE may reveal a palpable defect in the rectum and rigid anoscopy/proctoscopy may reveal intraluminal rectal blood or visible defect. When any of these findings are present, probability of rectal injury is as high as 95%. Nonetheless, the false neg rate of both tests is as high as 31%. In the absence of diagnostic findings in the context of a potential penetrating rectal injury, additional evaluation with a water soluble contrast study should be obtained. EUA is not necessary to make dx.

Answer 326

A Traditional receommendations for surgical mgmt of extraperitoneal rectal trauma incl proximal fecal diversionwith a colostomy, presacral drainage, distal rectal washout and repair of the injury. Little evidence to support most of these recommendations Only recommendation supported by data is proximal diversion with a colostomy. Presacral drainage is controversial; some studies have demonstrated a benefit with its use, whereas many others have shows that it is unnecessary and does not prevent pelvic sepsis. Distal rectal washout does not appear to provide any benefit adn may incr the risk of contam of the surrounding tissues. Direct repair is often not technically feasible and does not appear to improve outcome. In colon injury, 24 hr abx ppx is at least as effective as longer (3-5 days) abx administration in reducing infectious complications; these findings have been extrapolated to rectal injuries without additional verification.

Answer 327

D Pt has sustained a blunt panc injury, Panc injuries are tx based on location and grade. CT shows evidence of liekly ductal disruption corresponding to Grade III injury of distal panc. Surgical exploration with direct visualization or panc remains key diagnostic maneuver. When ductal disruption is proven or even highly suspected, distal panc is safest approach. If suspicion of ductal injury is low (grade I or II) or if the pt is physiologically unstable during OR, local drainage is appropriate. ERCP is reserved to identify ductal disruption in cases that present in a delayed manner. Most common complication assoc with sx tx of panc injuries is the formation of a panc fistula; however most resolve within 1-2 wks if nutrition and drainage are adequately provided.

Answer 328

E Tx of patient with a bladder injury depends primarily on whether the injury is intra or extraperitoneal. Conventional cystography or more recently CT cystography is the appropriate diagnostic modality. Equivalence of each diagnostic modality. Once the dx is identified, the tx incl non op mgmt by catheter drainage for 10-14 days, followed by cystogram to confirm closure of rupture. Indications for initial operative mgmt of extraperitoneal bladder injury incl concomitant injury to the rectum or vagina, injurry to bladder neck in woman, avulsion of bladder nexk in any pts and need for pelvic exploration for other surgical indications. Pelvic # alone does not mandate surgical exploration unless bony fragments remain within the bladder laceration Intraperitoneal bladder rupture should routinely be explored and repaired.

Answer 329

B Pt has RF for BCVI include high energy mechanism and a c-spine # of C3. Most appropriate screening test for blunt cerebral injuries has changed over time. CT a with a multislice (>16) scanner has significantly influences the screening algorithms for BCVI. High sensitivity and specificity with very few missed injuries. Most efficacious screening tool for BCVI

Answer 330

B Injury described here is Grade II on Denver grading scale for BCVI. Untx, this injury results in a stroke rate of ~25%. This high rate precludes observation as reasonable tx plan. There are some reports of stenting carotid injuries. There is little experience with stenting vertebral artery injuries. Early reports of carotid stenting for injuries resulted in a relatively high complication rate, incl occasional carotid occlusion. Generally, these pts are maintained on systemic anticoagulation after placement of stents. Surgical repair would be quite difficult on the vertebral artery at the second vertebral body. POsition and size of artery make exposure and repair technically difficult. Systemic anticoagulation dec incidence of ischemic neuro events. Systemic heparinization must be used with caution in pts with multiple trauma or closed head injury. Antiplatelet therapy is effective in reducing ischemic neuro events and may be used as an alternative to anticoag

Answer 331

B Five criteria necessary to be classified as having a low probability of cervical spine injury are as follows: 1) no midline cervical tenderness, 2) no focal neuro deficit, 3) N alertness, 4) no intoxication, 5) no painful distracting injury. When all 5 criteria are present, sensitivity and NPV of 99%. Even it pt denies neck pain, an exam to r/o midline tenderness is necessary. Three view c-spine XR are not necessary if all 5 criteria are present. Usually omitted due to availability of CT. Best indication for a simple lateral c-spine XR may be in the trauma bay in a hypotensive pt who has a suspected c-spine injury. CT would be appropriate if pt did not meet any of these 5 criteria. Such a intubated, painfully distracting injuries, neuro deficit or intoxicated. MRI is best used to dx a ligamentous injury or epidural hematoma of spinal cord

Answer 332

E Motorcycle crashes account for 10% of all motor vehicle crash fatalities and motorcycle crashes are 37x more lethal than automobile crases. TBI is a common cause of death and long term disability after a motorcycle crash and is estimated to cause >50% of deaths Motorcycle helmets decr the overall death rate of motorcycle crashes, the incidence of lethal head injury and the severity of nonleathal head injury in motorcycle crashes compared with nonhelmeted riders. States where motorcycle helmets are required by law for all riders have decr mortality and head injury compared with states with partial or no such laws. Helmeted motocyclists are 22% less likely than nonhelmeted riders to suffer a cervical spine injury after a motorcycle crash

Answer 333

B Screening and Brief Intervention (SBI) consists of the use of 1 of several screening questionnaired to identify pts with at risk alcohol consumption and behavior. Once identified by the screening questionnaire, these pts undergo a brief intervention that usually consists of counselling provided by the caregiver with the goal of helping pts decide to lower the risk of alcohol related problems. Result in significant reductions in drinking behavior sover time and significantly decr injury related risk behaviors and injuries req hosp adm. Less likely to be arrested for DUI within 3 yrs of d/c Also cost effective.

Answer 334

C Secondary brain injury after trauma is a significant contributor to pt mortality and may be the result of hypotension or hypoxemia. Goals of mgmt in TBI are to prevent this secondary injury, thereby limiting cerebral ischemia. Improved pt outcomes after severe TBI are noted with ICP <20, CPP >60, brain tissue oxygenation < 15, and jugular venous O2 sat >50%. Single systolic bp of <90 incr morbidity and mortality and thus, should be avoided.

Answer 335

1. A 2. B 3. D 4. E Lidocaine is recommended as pretreatment agent in RSI. Benefits include attenuation of reflex bronchospask and incr ICP. Other theorectical benefits are mitigation of tachyarrhytmias in response to intubation and reduced fasciculations with muscle relaxants. No strong evidence that pretreatmet with lidocaine improves the outcomes in pts undergoing rSI. Rocuronium is nondepolarizing neuromuscular paralytic agent used in RSI as an alternative to succinylcholine. Succinylcholine is generally the first choice, b/c it is of shorter duration and has been well established as a safe paralytic. Roc has a longer half life, which may compromise the neuro exam. However, it is an acceptable paralytic agent when succ is contraindicated: conditions of hyperkalemia, long standing myopathies, myasthenia gravis or a hx of malignant hyperthermia Induction agents of etomidate, propofol an ketamine are used to induce loss of consciousness. Etomidate is the most commonly used agent for RSI. It is a non barbiturate hypnotic with rapid onset and clearance. Minor effects on hemodynamics. Etomidate inhibits 11-beta hydroxylase enzyme in adrenal steroid production, which reduced serum cortisol. No evidence that a single dose affects pt outcomes Propofol is another nonbarbiturate hyponotic agent with very rapid onset activation. Shorter duration of action than etomidate. Known for its high amnestic and anti-emetic properties. Much more profound hemodynamic effects than etomidate and should be used with caution with hemodynamically labile pts. Ketamine is a disassociate induction agent that is also amnestic. Does not significantly decr resp drive. Does cause a release fo catecholamines and is often assoc with incr in HR and bp. Some conflicting views, ketamin incr cerebral blood flow and through this mechanism, may incr ICP. Little evidence that it further incr ICP in pts who already have intracranial HTN. Its sympathomimetic actions do give it the benefit of improving ventilation in pts with reactive airway disease.

Answer 336

1. C 2. B 3. D Base deficit and serum lactate levels correlate with mortality in trauma pts. In trauma pts, a persistently abN arterial base deficit is assoc with impaired oxygen utilization and incr risk of multiple organ failure. Serial base deficits have better predictive value than SBP for identifying pts who need significant transfusion. Others have determined that base deficit correlates only with mortality at 24 hrs and does not correlate with lactate levels except in non surviviors. They reported that early lactate levels correlate with infection, organ dysfunction, and return; specifically, risk of acute renal failure was minimal if lactate levels cleared within 24 hrs. Serum lactate but not base deficit was a predictor of mortality after major burns. Age and initial serum lactate as the only 2 significant variable for predicting mortality in burns. Early serum lactate and base deficit values are worse for burn pts who die and that elevated serum lactate values during the first 48 hrs after a burn are an independent risk factor for death. However, there is no threshold serum value for serum lactate that can be used to indicated that further resusc is futile

Answer 337

D CN 11 passes through the SCM, innervates that muscle and then passes through the posterior triangle of the neck to innervate the trapezius muscle at its anterior aspect, approx 1/3 of the distance along the muscle length from the clavicle. At the posterior triangle, the nerve is most exposed and most easily injured. Shoulder syndrome resulting from SAN injury often from LN operations in the posterior traiangle, includes shoulder weakness and commonly include pain that is considered neuropathic Often accompanied by a marked delay in dx, in part, b/c electrophysiologic testing may be inconclusive due to variable nerve innervation patterns in the neck. Extent of injury does not correlate well with testing and is better assessed by surgical exploration. Surgical correction can improve functional outcomes. Some injuries, incl those resulting from SLN Bx may be transient and improve with time without the need for surgical intervention. Such temporary SAN injuries are seen in up to 30% of pts undergoing SAn sparing functional neck dissections.

Answer 338

D HPV is well known to be an etiologic factor in the development of cervical cancer. Now strong evidence demonstrating a link between HPV, especially HPV type 16 and a subset of pts with H&N cancer, specifically OPSCC. Oropharynx consists primarily of the base of tongue and tonsils. Majority 60-80% are HPV positive. More likely to be younger, have less tobacco and alcohol exposure, and have more high risk sexual behavior compared with other SCC H&N cancer pts. Prognosis of pts with HPV assoc OPSCC is significantly better than smoking and alcohol related OPSCC regardless of tx strategy. These findings have led to the development of vaccine strategies to decr the incidence of HPV

Answer 339

D Patient hs a submandibular abscess. Most common etiology for an infection in submandibular space is peridental abscess. Other less common causes incl trauma to the oral cavity (e.g. mandibular #s), URTI, foreign bodies, mandibular/lingual malignancies, sialadneitis and lymphadenitis. Portal for submandibular infections is through the mouth. Thus abx must be directed against mixed flora of the oropharyngeal cavity, incl oral anaerobes (prevotella and peptostreptococcu), streptococci, staphylococci and gram neg. Broad spectrum abx should be initiated early in the tx of submandibular abscess Early, complete source control is important and surgical I&D are required. Attn to breaking up any loculated pus to ensure adequate drainage. Abscesses can progress into Ludwig angina--a rapidly spreading woody inflammation of the submandibular space that can present without evidence of cellulitis. When an odontogenic source of abscess is suspected, dental consult should be obtained. Scrofula is a tubercular infection of neck LNs that does not present with the acute inflammatory changes seen in this picture. Thus, medical tx for tb is not required.

Answer 340

B Melanomas of H&N generally follow a more aggressive coure than melanoma of the trunk pr extremities. Mucosal melanomas are even more aggressive: 26% of pts with mucosal lesins present with metastatic disease in the regional LNS at the time of dx. Regional lymphadenecctomy is teh standard of care for pts with clinically palp lymphadenopathy, but controversy persists with response to mgm of the clinically neg neck. Removal of clinically occult, pathologically posiive disease does not result in better locoregional control and better OS. Trials failed to demonstrate an OS advantage for elective LN dissection compared with therapeutic LN dissection once disease become clinically apparent. Further, no survival advantage is conferred by elective node dissection even in patients with T4N0 disease. Large series shows that delayed regional lymphadenectomy, defined as more than3 months after dx, was assoc with a better survival than elective node dissection (ciinically neg) where pathologically positive ondes were identified by SLN. Occult nodal mets may impart and immune stimulating effect. Recurrence rates are also higher in necks after nodal dissection compared with recurrance rates after lymphadenectomy in the axilla or groin. Melanomas of H&N metastasize to predictable nodal groups in >90% of pts. Involvement of postauricular and drainage to contralateral neck is uncommon. No effective adjuvant therapy confers an OS advantage for H&N melanoma including interferon alpha. HIgh dose interferon for 1 yr offers no advantage over low dose interferon for 2 yrs. Historically, melanoma has been considered a radio resistant tumor, but a small study demonstrated 95% disease control in pts with H&N melanoma >1.5 mm and cN0 necks with radiation of 6Gy twice weekly for a total of 30Gy

Answer 341

D Perc trach has supplanted open trach for hemodynamically normal critical pts requiring prolonged mechanical ventilation. Generally well tolerated in elective setting, every effort should be made to effect a safe transition from oral/nasal endotracheal intubation. Significant coagulopathy, pulm and hemodynamic instability and incr ICP should be addressed before undertaking placement. Relative contraindications include morbid obesity, prev RT or burns to neck, and c-spine #, instability or fusion. B/c of risk of damage to their soft cartilaginous airways, perc trach is absolutely contraindicated in children <12 yrs old. In cannot intubate, cannot ventilate scenarios, cricothyrotomy remains the standard of care for securing an emergent airway in adults, particularly in the face of tracheal trauma or tumor. Emergent airway in a child is usually managed with tracheostomy, secondary to fear of cricoid injury,

Answer 342

A RLN provides sensory and motor fcn to the vocal cord. R RLN arises from the vagus nerve and travels around the R subclavian artery before ascending in the TE groove to enter the larynx A R non-RLN occurs in 0.6% of pts and may be seen in the setting of an aberrant R subclavian artery. In this case, the nerve takes a direct course in the neck from the vagus nerve to the larynx without coursing in the mediastinum. Travels either with the superior thyroid vessels or parallel with the inferior thyroid artery The L RLN arises from the vagus and travels around the aorta before ascending vertically in the TE groove to enter the larynx. A L non-RLN occurs in 0.04% of pts and is assoc with situs inversus.

Answer 343

C Potential surgical complications of parotidectomy include facial nerve dysfcn, salivary fistula, Frey syndrome and infection. Facial nerve dysfcn occurs in 30-60% of pts after parotidectomy and improved to N fcn within 1 yr in >90% of pt. Risk of facial nerve palsy incr in pts with sialadenitis and multiple histologies within the same gland. Use of intraop facial nerve monitoring does not decr risk of facial nerve palsy. ~10% of pts undergoing parotidectomy develop a salivary fistula and pts with sialadenitis are at incr risk. Most salivary fistulae resolve spontaneously without surgical intervention. Unilateral gustatory sweating and flushing or Frey syndrome occurs in 10% of pts postparotidectomy pts. Cause by inappropriate regeneration of severed autonomic fibers; therefore it typically occurs as a late complication, with a median time to development of 11 month. Managed conservatively with topical anticholinergics and botox injection. Typically resolves within 2-4 yrs after sx

Answer 344

A Of the 4 branchial clefts visible in the 5th week of gestation, only the most dorsal portion of the first cleft persists as the external auditory canal. Anomalies of the first branchial cleft arise from incomplete closure of the ectoderm on what is destined to be the floor or the external auditory canal. Tract follows the seam between the mandibular and hyoid arches, ending on the face or in the submandibular region. Often dx after infection. First branchial cleft abN are often located close to the parotid gland, especially the superficial lobe that overlies the lesion. Permanent cure can be achieved by only complete surgical excision with wide exposure of the lesion. Superficial parotidectomy and exposure of the facial nerve are required in most cases, making facial nerve injury a significant risk of the operative procedure Second branchial cleft anomalies are the most common abN, followed by the first branchial cleft abN. Second branchial cleft anomalies usually appear anterior to the anterior border of the sternal head of the SCM. Anomalies of the third and fourth branchial clefts or pouches are rare. Although somewhat controversial as to their origin, 3rd or 4th branchial cleft anomalies almost always occur on the L side of the neck adn may present as suppurative thyroiditis. L hemithyroidectomy is usually needed as part of then en bloc dissection of this anomaly, b/c the tract travels through or in proximity of the upper L lobe of the thyroid. After it leave the thyroid gland, the tract tracels cephalad in proximity to the superior laryngeal nerve and the hypoglossal nerve then deviates medially to the piriform sinus. There is no 5th branchial cleft.

Answer 345

B With the advent of perc trach has come an incr used of early trach in pts suspected of requiring prolonged mechanical ventilation. Many benefits to early trach. Early trach are assoc with a significantly reduced need for sedation, esp deep sedation, compared with translaryngeal intubation in those pts who required prolonged mechanical ventilation. No qol improvement with early trach, and ventilator free days were not improved by early trach. Risk of pneumonia is not altered by timing of trach.

Answer 346

A DDx or parotid masses is extensive and incl infections and inflam processes, autoimmune processes, benign and malignant primary parotid tumors and met lesions. H&P to direct diagnostic work up. Ask about other disease processes that can affect the parotid including Sjogren's syndrome and RA. Physical exam of H&N evaluating for other masses or lesions on mucosal surfaces. Character of mass itself--firm vs fluctuant is important. Facial nerve fcn must be assessed FNA of mass is usually next step in eval. Accuracy of dx is 90%. Based on dx identified on FNA< futerh imaging may be required to evaluated the involvement of the primary lesion with surrounding structures to look for metastatic disease in case of malignancy. CT is usually modality of choice although MRI may be better at delineating mass relationship with facial nerve Most parotid masses are neoplasms; 75-80% are benign. Most common benign neoplasm is a pleomorphic adenoma. Remainder are either Warthin tumors, oncocytomas or monomorphic adenomas. Although, most parotid masses are unilat, Warthin's tumor is unique in that it frequently presents with bilat masses and multifocal lesions within the gland. Most common parotid malignancy is mucoepidermoid cancer. Other malignancies include acinic cell carcinoma, adenoid cystic carcinoma and adenocarcinoma Tx of most parotid masse requires a superficial parotidectomy. At time of resection, extent of mass may dictate further resection. If the facial nerve is functioning before the procedure, it should be preserved if possible. If it is not functioning preop, resection of the nerve can be undertaken if necessary. LN should be managed based on preop imaging and node evaluation. If positive nodes are identified or suspected, a neck dissection should be undertaken. Ddx for bilat parotid masses include infection or neoplasm. Only neoplasm with bilaterality is Warthin tumor.

Answer 347

A When met SCC is identified in cervical LNs, initial eval is directed toward identificaiton of the primary. H&P ples CT of H&N will detect the H&N primary in up to 50% of cases. Panendoscopy including laryngoscopy, esophagoscopy, nasopharyngoscopy, and bronchoscopy facilitates bx of suspicous areas and ares of potential occult primary tumor, such as tonsil, pyriform sinus, base of tongue and nasopharynx. Location of cervical LNs helps predict locaiton of primary and directs diagnostic eval. Lung primary is suspected when met SCC is detected in supraclav nodes. Dx of met SCC to cervical LNs can be made with FNA cytology. Excisional LN bx is neither indicated nor necessary for dx. May be detrimental in the setting of met SCC b/c it may complicate further formal lymphadenectomy once the primary is identified.

Answer 348

D Injury to the spinal accessory nerve is often iatrogenic, classically occurring when a LN is removed from the posterior cervical chain. Other causes of an accessory nerve injury include blunt and sharp trauma to the enck as well a skull base and foramen magnum pathology Accessory nerve is purely motor nerve. After exiting the cranium, it passes deep to SCM and then passes under the trapezius . Innervates these 2 muscles: SCM rotates the head to the opposite side and the trapezius stabilize the scapula, elevates the shoulder, and assists with scapular adduction and arm abduction at the shoulder Usually present with dull ache of the shoulder, an inability to use the affected arm overhead, scapular winging, and atrophy of the trapezius. B/c the spinal accessory nerve is superficial and readily exposed, early surgical exploration and repair should be considered, especially with iatrogenic or sharp lacerating injuries. As with other nerve injuries, graft length and timing of repair determine outcome. B/c this nerve is a pure motor nerve, an early repair has an excellent change of good recovery.

Answer 349

B Esophageal diverticula can arise anywhere along the esophagus, pharynoesophageal or Zenker diverticula are most common and account for 60-65% of all esophageal diverticula. Traction diverticular are typically found in the midesophagus and result from distraction caused by an adjacent inflammatory process. Pulsion diverticular are the most common type and result from herniation of mucosa and submucos athrough a weakness in the muscular wall from incr intraluminal pressure. Zenker diverticula are an example of pulsion diverticula that originate in Killian triangle, which the the weak point in the posterior esophagus between the oblique fibers of the inferior constrictor muscle and the transverse cricopharyngeal muscle. 2-3x higher rate in men tha women, most commonly in the 6th decade of life. Barium esophagram is the best diagnostic study and will typically show a posterior midline protrusion just above the cricopharygngues. Sx remains the standard tx and can be accomplished by either diverticular resection or suspension with myotomy. Endoscopic stapled esophageal diverticulostomy is also an option.

Answer 350

1. C 2. A 3. A Thyroglossal duct cyts are one of the most common neck masses in children, second to adenopathy and are almost always discovered in that age group. 2/3 are dx in the first 3 decades and 50% are apparent by age 10. They occur within 2 cm of midline and carry a risk of infection. Due to risk of infection, excision is recommended. If infection occurs, aspiration and abx are recommended. Open I&D risk seeding cells outside the cyst, which increases risk of recurrence Lingual thyroid is uncommon with an estimated incidence of 1 in 100,000. It is often asymp, and as a result, is more often dx later in life. Tx can be nonsx (thyroid suppression) or sx, but sx is recommended only if symp occur b/c of the probably need for long term thyroid supplementation after surgical resexn. MIS approaches are described using a transoral and endoscopic approach.

Answer 351

1. C 2. A 3. B Gustatory sweating aka auriculotemporal or Frey syndrome, manifests by hemifacial sweating or flushing in assoc with meals. Injury to sympathetic and parasympathetic fibers of the prox auricotemporal or lingual nerve is thought to precipitate the syndrome. The aberrant regeneration theory suggests that regeneration of PSNS fibers into SNS pathways to salivary tissue and blood vessels acount for the symptoms. Interestingly, sweating with salivation is more common in men and flushing is more common in women. Injury is most commonly assoc with sx of the parotid but has also been assoc withsx of the submandibular gland, mandibular condyle #, forceps injury to the fetus during delivery, autoimmune neuropathy in diabetes, and herpes zoster infection. Incidence varies 10-40% of pts who have parotidectomy, depending on how aggressively the condition is sought. B/c regeneration of neural fibers takes time, syndreom may not present months to yrs after injury Neurotransmitter responsible for these benign but socially troublesome symptoms is controversial. Acetylcholine has been implicated, b/c botulinum toxin blocks acetylcholine release at the cholinergic neural terminal glands and abolishes cholinergic activation of sympathetically denervated sweat glands during salivation. Botox has become first line tx but repeated injections are usually necessary. On the contrary, flushing has been observed to persist after sweating has been abolished by atropine. Nitric oxide and VIP have also been proposed to contribute to gustatory sweating. Blockage of these 2 neurotransmitters has not been used clinically to date. Minimization of parotid wound bed, development of thick flaps during sx, placement of an interposition barrier with a temporoparietal fascial or muscle flab between the surgical bed and skin and post op radiation therapy have been proposed to minimize the occurrence of the problem First bit syndrome refers to pain n the parotid region after the first bite of a meal after surgery in the parapharyngeal space. Can also occur from tumors in the parapharyngeal space, commonly schwannomas. Like Frey syndrome, etiology is through to be denervation of the cervical sympathetic nerves. Proposed trigger of what can be exquisite but self limited pain, is the supramaximal response by myoepithelial cells to parasympathetic stimulation induced by chewing or biting. Usually, however, the pain is mild and lasts only a few seconds. When severe, it may limit the pt's desire to eat. The post op manifestation occurs within 5-7 days after surgery abd 50% will demonstrate a concomitant Horner's syndrome. Mgmt of the problem is difficult but fortunately, most pts experience resolution over time. Botox has been reputed to be effective in amelioration of symptoms in a few case reports.

Answer 352

C Pt presents with hx and OR findings of carcinoid tumor and syndrome. Sm bowel resection is indicated to relieve the bowel obstruction and b/c this is likely the primary tumor. In some series, resection of the primary even in pts with liver mets appears to have a favorable impact on survival. Some surgeons will perform routine appy or even R hemi to remove a possible primary. However, the tumor is uncommonly in the appendiz and blind appy/R hemi will add little in a pt with diffuse mets Some studies suggest that debulking of 70% of the tumor can improve symptoms, but this is unlikely to be achieved by hepatic resection b/c the mets are typically bilobar and outside the liver, as in this pt with mesenteric disease and extensive liver involvement. This hold true for the resection of the mesenteric disease which may add significant morbidity. Rather, pts with extensive liver disease and mesenteric disease may have better outcomes (and a low incidence of bowel infarction) by simply removing the primary and tx the liver diseas later with chemoembolization, RFA or systemically with octreotide. This patient is likely to be on long term octreotide therapy, which causes gallbladder sludge and therefore cholecystectomy is indicated

Answer 353

D Pt presents with symptoms (refractory ulcer symptoms, diarrhea) and signs (cluster of H pylori neg ulcers) suggestive of Zollinger Ellison syndrome caused by gastrinoma. Possibility needs to be investigated. ONly 20-25% of such tumors are related to MEN1, with the rest being sporadic. Therefore lack of MEN 1 fam hx does not rule out the dx of gastrinoma B/C PPIs can incr serum gastrin up to 5x in non ZES pts, ZES cannot reliably be ruled out in any pt while being tx with a PPI. PPIs have a long half life and fasting serum gastrin levels and secretin provocative test should not be done until PPI has been stopped for 1 week. During that period, pt should have no active peptic disease and should be tx with high dose H2 blockers, which have shorter half lives than PPIs and can be stopped 48 hrs before the test After dx of ZES is made, determination of tumor extent and location are essential to management. Most sensitive test is somatostatin receptor scintigraphy with single photo emission CT (SPECT) imaging. CT and MRI with contrast are also useful. EUS is useful for detecting many pancreatic tumors but 70-90% of gastrinomas occur in the duodenum and EUS detects fewer than half of those

Answer 354

D Tall cell varian of papillary cancer takes a more aggressive path than the usual variant. Noted to have more freq LN mets, higher % of recurrent disease and much higher disease related mortality than the usual variant group. FNA often defined papillary thryoid carcinoma in distinction from follicular cells need histologic assessment. FNA in combo with frozen section detected all cases of tall cell variant papillary thyroid carcinoma, in those patient, the majority were defined by FNA In a tall cell variant papillary thyroid carcinoma measuring 2.5 cm, nodal dissection is indicated given the high likelihood of nodal disease. As such, appropriate surgical mgmt of this pt would be total thyroidectomy with complete central neck dissection. This ppx dissection includes at minimum, prelaryngeal, pretracheal and at least 1 paratracheal LN basin based on the side of the primary tumor. Thi is removal of prelaryngeal, pretracheal, and both L and R paratracheal nodal basins from the level of the precricoid, pretracheal, largyngeal (delphian node) to the level of the innominate artery Subtotal thyroidectomy would not be indicated in a pt with a 2.5 cm papillary carcinoma. Total thyroidectomy without nodal dissection would be inadequate. Further, total thryoidectomy with berry picking of grossly abN nodes would leak at risk clinically normal nodal basin behind, incr risk of local recurrence. Total thyroidectomy with central neck dissection and added L modified radical dissection is not indicated; only a central node dissection is necessary for appropriate surgical mgmt

Answer 355

D Sporadic form of MTC accounts for ~80% of cases of this disease. In this pt with a clear fam hx of MTC in several first degree relatives across generations, a familiary syndrome must be considered. Inherited tumor syndromes with MTC as a component include MEN2a (most common), MEN 2b (less common but most aggressive form), and familial MTC. Evidence suggests that famlial MTC is a phenotypic variant of MEN with low penetrance for pheo and PHPT. MEN 2b is distinguished from MEN 2a by absence of PHPT. With the fam hx of HTN crisis leading to death and death during bx of an adrenal mass (likely due to HTN crisis), this pt with bilar adrenal masses most likely has bilat pheos Primary aldosteronism, Conn syndrome is characterized by adrenocortical adenoma secreting aldosterone causing arterial HTN and hypokalemia. Not assoc with MTC. Cushing disease represented 70% of cases of Cushing syndrome. More than 90% of cases of Cushings are cause by pituitary microadenomas. Pituitary adenomas can be seen in MEN 1, which is characterized by PHPT, enteropancreatic endocrine adenomas (gastrinoma, insulinoma, nonfunctionning neuroendocrine panc tumors) and pituitary adenomas. MEN 1 is not assoc with either MTC or pheos. Met disease to both adrenals from MTC is unlikely b/c most common site are lung and bone MTC derives fron neuroendocrine parafollicular C cells of the thyroid. All 3 inherited formed of MTC are autosomal dominant. Mutations in RET protooncogene occur in ~90% of kindreds with inherited forms of MTC. Allows prospective screening of family member in known kindreds feasible long before the onset of symptoms. Testing for RET protooncogene has replaced teh traditional approach of stimulating secretion of calcitonin by pentagastrin or calcium infusion. Genetic testing is more sensitive and specific in these kindred and allows identification of the specific mutation, which can be prognostic implications and drive therapeutic decisions such as timing for ppx thyroidectomy

Answer 356

A In pts with RET proto oncogene mutations, nature of mutation determines the risk of developing MTC and the aggressiveness of the disease. All pts with MEN2b have highrisk mutations as characterized by the ATA. Current recommendations or pts from families with MEN2B are RET testing ASAP w/in the 1st yr of life and if present, ppx total thyroidectomy before age 1. Ppx bilat adrenalectomy is not indicated infants with MEN2b. Routine screening for pheo is recommended to being at age 8 with specific RET mutations and age 20 with the remainder. Neither hypophysectomy not parathyroidectomy is inicated in this pt b/c MEN 2b is not assoc with pituitary adenomas or PHPT. Observation is inappropriate b/c of high risk of early development of MTC and difficulty curing it once present.

Answer 357

A Alterations in hypothalamic-pituitary-thyroid axis during critical illness are callled the euthyroid sick syndrome. Majority of the pts are actually euthyroid. However, current terminology favors nonthyroidal illness or the low T3 syndrome. Alterations occur relatively rapidly and within 2 hrs of the onset of acute stress, there is a drop in the levels of circulating T3 and an incr in the levels of serum reverse T3. In general, nonthyroidal illness syndrome is characterized by low serum T3, normal T4, normal TSH and elevated reverse T3. Levels of circulating T4 depend on the length and severity of critical illness, with an initial brief rise, subsequent normalization and ultimate decline. Despite the decline in both T3 and T4, levels of thyrotropin remain N until late in critical illness. TSH is initially N to sl elevated, although it also declines during the chronic phase of critical illness. Thyroid replacement is not indicated in the acute phatse of critical illness when the dx of non thyroidal illness syndrome is made. Less clear whether tx should be initiated in the chronic phase, when levels of T4, TSH and thyrotropin releasing hormone in addition to T3 are low. There is no evidence that tx imroves morbidity or mortality. In the setting of clinical deterioration without other explanation, some physicians do recommend tx. If this is the case, it should be provided as IV T3 due to the decr conversion of T4 to metabolically active T3

Answer 358

A Galactorrhea or inappropriate lactation is a relatively common problem that occurs in 20-25% of women. Lactation requires the presence of estrogen, progesterone and prolactin. Ddx of galactorrhea incl pituitary adenoma, neuro disorders, hypothyroidism, adrenal insufficiency, med side effect, breast stimulation, chest wall irritation and physiologic causes. WU should incl a preg test, prolactin level, renal and thyroid function tests, and where appropriate, MRI of the brain to r/o pituitary adenoma. Prevalence of hyperprolactinemia in women with secondary amenorrhea is ~10-25%. In women with both amenorrhea and galactorrhea, rates incr to 75%. Causes of hyperprolactinemia include prolactin producing pituitary tumors, adrenal insufficiency, and hypothyroidism. Prolactinomas account for ~40% of pituitary tumors with an estimated prevalence in the adult populaiton of 100 per million. Occur most freq in women ages 20-50 with gender ration 10:1 Lab most likely present in this case is an incr prolactin. Incr serum cortisol, incr ACTH, and decr TSH do not elevate prolactin levels. Incr calcitonin is not assoc with galactorrhea.

Answer 359

D Adrenal gland is a dual fcn endocrine organ divided into cortical and medullar regions. Cortical region has 3 distinct zones, each producing specific hormones, where as the medullar region produces and releases catecholamines. Adrenal incidentalomas are defined as adrenal lesion discovered on diagnostic imaging studies obtained for nonadrenal related indications. Can be found as freq as 5% of the time on CT. WU hinges on functionality of the lesion and its size. Functional adenomas in the cortical region of the adrenal gland typically arise in the zona glomerulosa (aldosteronoma) or fasiculata (cortisol producing tumor). Medulla can develop catecholaimine producing pheos. Catecholamine-producing tumors can also arise in the paraganglia along the aorta and IVC (paraganglionomas). WU includes 24 hr urine metanephrines, serum potassium, 24 hr urine free cortisol or overnight dexamethasone suppression test. Non functioning incidentalomas larger than 4 com should be considered for resection b/c the risk of a lesion being an adrenocortical carcinoma incr with incr size

Answer 360

B Pheos are rare catecholamine producing tumors of enterochromaffin origin. IN adults, 90% arise in adrenal medulla, although they can originate in the paragnaglionic tissues anywhere from brainstem to bladder. Common extra adrenal locations include the origin of the IMA (i.e. the organ of zuckerkandl), bladder, heart, mediastinum, and carotid bodies. 90% of pheos are unilat and benign. Common presenting symptoms include h/a, diaphoresis, and palpitations, although many remain asymptomatic. Dx is made via demonstration of elevated urine and plasma catecholamines and their metabolites (i.e. VMA, metanephrines). B/C volume contraction from chronic catecholamine release can lead to severe hemodynamic instability during GA, pre op prep of pts with pheo is essential. Alpha adrenergic receptor blockade should be initiated 1-4 wks before sx using a selective agent like phenoxybenzamine (10 mg PO BID to start). Dose is escalated until pt experiences orthostatic hypotension. Beta blocker is added as necessary tx for tachycardia. Should not be initiated before the alpha blocker, however, to avoid the development of malignant HTN

Answer 361

A Ectopic pheos are rare, potentially lethal, catecholamine secreing tumors arising from enterochromaffin positive staining primary neural crest cells. Tumors are also referred to as paragangliomas or extra adrenal pheos. Majority are sporadic. Approx 10% are familia with an autosomal dominant inheritance. May also be assoc with MEN, von Recklinghausen neurofibromatosis, sturge weber syndrome, vHL, and tuberous sclerosis. In adults, 30-40% of ectopic pheos are malignant compared with fewer than 10% of adrenal pheos. 15-24% of ectopic pheos are reported to be multicentric. Most commonly located within the abdo cavity, typically in the superior para-aortic region, para-adrenal area and organ of zuckerkandl. Less freq, these tumors are identified in the urinary bladder, mediastinum and aortopulmonary window. Mainstay of dx off all types of pheo is measurement of urine catecholamins and catecholamine metabolites as well as plasma free metanephrines. In most cases, pheos can be localized with MRI, MIBG scan or CT

Answer 362

C Pancreatic neuroendocrine tumors (PNETs) = pancreatic islet cell tumors or pancreatic endocrine tumors. First step after dx of panc malignancy is differentiation of neuroendocrine cancer from panc adenoca. PNETs are also distinct from carcinoid which have similar histologic appearance but arise in bronchi, small intestine, appendix, or rectum. Most PNETs occur sporadically but can be assoc with inherited genetic syndromes; approx 10% may be assoc with MEN 1. PNETs are also assoc with MEN2, vHL, TS and NF. Grade can vary from well to poorly differentiated with incr aggressiveness. Most sporadic PNETS are well diff, there is marked variability in tumor growth. B/c most are nonfunctional and nost assoc with sympt or hormone hypersecretion, prolonged silent progression is common. Most identified incidentally during imaging for other indications or at an advanced stage when pts become symptomatic from tumor bulk. Conventional imaging detects >70% of PNETs >3 cm but less than 50% primary tumors <1 cm. Numerous small liver mets on the surface of the liver are often missed on imaging. B/C more than 50% of PNETs have identifiable liver mets and a large unknwon fraction have occult mets, most patients with clinically significant PNETs have liver mets at dx. Serum chromogranin A is a neuroendocrine secretory protein that serves as a marker of disease activity in nonfunctional PNETs and can assis in staging and monitoring. CGA may decr in pts responding to therapy. In absence of distant mets or significant comorbidities, complete surgical resection of primary tumor should be attempted. By contrast with pts with panc adenca, hepatic resection may be beneficial in pts with met PNETs. Resection to render pts free of macroscopic disease and to diminish systemic symptoms. Hepatic resection is generally favored in pts with limited hepatic disease but is not beneficial in the setting of diffuse disease. Unfortunately, surgical resection of at least 90% of all visible tumor is possible in only 5-15% of pts with PNETs with hep mets. PNETs are more responsive to chemo than are carcinoid tumors. In animal trials, combo of streptozocin and doxorubicin was assoc with a regression and survivial benefit comparted to streptozocin and fluoruracil. 3 drug regimen of stretozocin, 5-fu and doxorubicin was assoc with an overall response rate of 39% and median survival of 37 months. Newer chemo agents including temozolomide based, VEGF pathway inhibitors, and mTOR inhibitors.

Answer 363

B Cushing syndrome is chronic glucocorticoid excess leading to symptoms and signs such as muscular weakness, central obesity, abdominal striae, HTN, DM, and immunosuppression. Pts usually present with moon facies, buffalo hump, thin limbs with central fat, easy bruisability, hirsuitism, and acne. Exogenous or iatrogenic Cushing syndrome is common and caused by incr glucocorticoid intake. Endogenous or primary Cushing syndrome can be divided into two categories: ACTH dependent and ACTH independent Pituitary Cushing syndrome or Cushing disease is the most common form of Cushing syndrome and is cause by an ACTH secreting pituitary adenoma. Localization with CT head or MRI. Other type of ACTH dependent Cushing is ectopic ACTH secretion, which accounts for 10-15% of cases. Most common neoplasms causes ectopic ACTh secretion are small cell lung cancers (50%), malignant thymic tumors (20%) and less commonly, neuroendocrine tumors of the pancrease or gut (carcinoid), medullary thyroid cancer, and pheo. CXR is useful for dx of small cell lung cancer, the most common cause of ectopic ACTH secretion. ACTH independent causes of Cushing's syndrome are unilat adrenal adenoma (10%) and adrenocortical carcinoma (10%). CT Abdo can localize most ACTH independent lesions. Presence of bilat adrenal lesions, iodocholesterol scanning is helpful to determine which adrenal gland contains the hyperfunctioning adenoma. Biochemical dx with variety of tests. Low dose dexamethasone suppression test consists of administering 1-2 mg of dexamethasone at 11 pm with plasma cortisol measured at 8 am the following day. Pts without Cushing syndrome have suppression of plasma cortisol with dexamethasone tx, which does not occur in pts with Cushing syndrome. Dx can also be provided by 24 hr urine levels of free cortisol and midnight salivary cortisol levels. Spot uringary cortisol is not reliable in the dx of Cushing syndrome b/c levels must be measured over a 24 hr period. C peptide level is used to dx hyperinsulinism.

Answer 364

E Dx of pheo and paraganglioma relies on biochemical evidence of catecholamine production by the tumor. Biochemical testing in symptomatic pts, pts with adrenal incidentalomas, and pts who have a hereditary risk for developing a pheo or paraganglioma. CT or MRI is recommended for initial tumor localizaion with MRI preferred in children and pregnant or lactating women b/c of concerns regarding ionizing radiation. Both CT and MRI are not needed. MIBG is oftne used in pts with pheo. In a recent study, MIBG did not provide additional data in the majority and di not change the surgical mgmt. Therefore, mIBG is not reqd before initial operative intervention. PET is not as sensitive as CT or MRI and does not add new info in the majority. Somatostatin scintigraphy is used to identify GI neuro endocrine tumors. Sensitivity is lower than MIBG for pheo and no change is operative mgmt is identified by the use.

Answer 365

E Routine benefit of post op RAI in low risk pts underoing total thyroidectomy for differentiated thyroid cancer is unclear. Several factors determine recurrence and mortality risks in pts with thyroid cancer. Young pts <45 yrs with well diff papillary or follicular tumors < 4 cm, no direct extrathyroidal extension beyond thyroid capsule or evidence of nodal or distant mets, are considered to have a low risk of recurrence. Nodal status may not be known at the time of initial OR b/c formal nodal dissection is freq reserved for those ots with overt nodal disease or those with a supicious preop neck U/S RAI is used to eradicate persistent neoplastic foci in the thyroid bed and LN basins, as well as remnants of non neoplastic thyroid tissue capable of producing thyroglobulin. In doing so, RAI facilitated surveillance and may decr disease recurrence. Thyroglobulin measurement after total thyroidectomy and RAI detection after ablation is a sensitive marker of tumor recurrence. Routine post op RAI is currently not recommended for stage I, low risk patients. However, post op RAI is indicated, even in the absence of nodal disease, if thyroglobulin antibodies are present. Thyroglobulin antibodies are present in up to 25% of with thyroid cancer. Goal of RAI in the presence of thyroglobulin antibodies is suppression of source of antigen, which facilitates the disappearance of antibodies and improves future thyroglobulin detection.

Answer 366

E Not a clear biochemical dx of PHPT in this patient. Additional biochemical workup in the pt should include ionized calcium, Cr, albumin, and 25-OH vit D levels. A chloride:phosphoate rarop >33 lends further support to the dx. Vit D def is common in the setting of PHPT and warrants replacement b/c incr PTH results in incr clearance and degradation of Vit D. A 24 hr urine collection for calcium and cr may also be indicated to exclude a renal calcium leak causing a secondary rise in PTH. Once the biochemical dx of PHPT is confirmed, parathyroidectomy is recommended for symptomatic pts. PHPT is characterized by hypercalcemia in the face of a nonsuppressed PTH leve. This common, often asymp, endocrine d/o affects approx 0.3% of the general population but up to 3% of postmenopausal women. Although the disease spectrum is wide, general guidelines for sx in an otherwise asymp pt require a total correct serum calcium > 1,0 above the upper limit of N for the local lab, Crcl <60 and evidence of abN bone density -2.5 or less. 24 hr urine fractional exrection of calcium is also indicated for this pt to r/o familial hypercalcemia as a cause of her mild hypercalcemia with an elevated PTH Many medical therapies may also influence PHPT and its clinical manifestations. Bisphosphonates and estrogen may be as effective as sx in incr bone density in pts with mild PHPT. Cincalcet is a calcimimetic agent that binds to calcium sensing receptors on parathyroid cells and causes these receptors to become more sensitive to serum calcium, suppressing PTH releast through neg feedback. Only approved for use in tx secondary hyperparathyroidism with chronic renal disease or parathyroid cancer as well as complicated nonop candidates.

Answer 367

A Approach to evaluating an adrenal incidentaloma should focus on 2 issues: whether the lesion is malignant and whether it is hormonally active. All primary adrenal tumors with suspicious radiological findings and most functional tumors should be resected. Tumors at least 4 cm that lack characteristic benign features on imaging should be resected. Non contrast and contrast CT attenuation expressed in Hounsfield units (HU) is a sensitive tool for differentiating benign from malignant adrenal massed. Lesion with <20 HU on noncontrast CT has a 100% specificity of being benign. Characteristics of malignancy suggested on CT include a large (>6 cm) lesion, presence of irreg borders, inhomogeneity, calcifications, and contrast washout <40% after 15 mins. B/c 4-7% of incidentalomas are pheos, asymp pts with an incidentlaly identified adrenal mass should be screened for hormonal activity. Measurements of urine fractionated metanephine and catecholamine levels is less sensitive than fractionated plasma free metanephrines, although plasma levels alone are not specific for the dx. Free urine cortisol levels and plasma adrenocorticotropic hormone and aldosterone to renin levels may also be helpful in detecting hormonally active adrenal masses.

Answer 368

C Papillary thyroid cancer is the most common histologic subtype of thyroid cancer. Sx is the mainstay of tx. Total thyroidectomy is recommended for tumors >1.0 cm. Total thyroidectomy not only facilitates post op RAI and surveillance with thyroglobulin measurement (both not feasible after lobectomy alone) but also decr the risk of local recurrence and improves survival compared with lobectomy Regional LN mets in pts with PTC are present at the time of dx in 20-90% of cases, depending on the method of detection. The central neck (level 6) is the most common site of nodal mets. Complete central neck dissection (bordered by the hyoid bone, inominate vein, and carotid sheath bilat) at the time of thyroidectomy is recommended for pts with preop or intraop identified involved central or lateral neck nodes. LN mets in the central neck may not appear abN on preop imaging or with intraop inspection in some pts, thus leading to the consideration for ppx central neck dissection, particularly in pts>45 yrs old who may be upstaged by the presence of LN mets. LNs in the lateral neck (levels 2-5) may be involved with PTC. Modified radical neck dissection is recommended for preop or intraop identified involved lateral neck nodes. Ppx modified radical neck dissection is not recommended for PTC.

Answer 369

D Inferior parathyroid glands arise from the third pharyngeal pouch and migrate with the thymus in a plane anterior to the recurrent laryngeal nerve (RLN). Inferior glands are typically within 1 cm of the inf pole of the thyroid. Other important locations for inferior glands include the cervical thymus (22%) and initimate with the thyroid capsule (17%). Superior glands arise from the fourth pharyngeal pouch and remain close to the posterior mid thyroid in a plane posterior to the RLN. With this more limited migration, there is less variability in the location compared with the inferior. Majority of superior glands (85%) are within a 2cm diameter area centered 1 cm above the intersection of the inferior thyroid artery and the RLN. May extend posterior and caudal to the inferior thyroid artery deep in the TE groove. Important to carry the surgical dissection back to the prevertebral fascia to identify superior glands that can be posteriorly situated in the paraesophageal and retroesophageal position. Approx 3% of ectopic superior parathyroid glands are at or above the superior pole of the thyroid. Incidence of supernumerary parathyroid glands is 10-15%. Most common location for a supernumerary gland is the thymus. Additional, more rare site of ectopic parathyroid flans include the carotid sheath and inside the thyroid gland

Answer 370

C Thyroid nodules are common in the population (5% palp, 50% US). Most are benign. Best dx tool for evaluation of euthyroid nodules is US guided FNA. Potential cytologic results obtained by FNA include benign, malignant, nondiagnostic (inadequate cellularity for evaluation), and indeterminate (meets cytologic criteria for specimen adequacen but lesion is incompletely characterized by cytology alone). Benign has <1% risk of malignancy. Atypia of undetermined significance 5-10%. Suspicious for follicular neoplasm 20-30%. Suspicious for malignancy 50-75%. Malignant 100% Benign cytologic category include nodular goiter, chronic lymphocytic thyroiditis, hyperplastic nodule and colloid nodule. For asymp nodules with benign cytology, FU at 6-18 month intervals for 2-5 yrs. Repeat FNA, which may include application of molecular markers is sggested for asymp nodules with AUS. B/C of indeterminate risk of malignancy (20-30%), sx is typically recommended for definitive dx of nodules characterized as suspicious for follicular neoplasm by cytology. Ddx for nodules in the suspicious for follicular neoplasm category includes adenoma (majority), follicular variant of papillary cancer (~50% of malignant nodules) and follicular cancer. Sx is recommended for nodules characterized as malignant or suspicious for malignancy by cytology.

Answer 371

D MTC accounts for 5 % of all thyroid cancers cases in the US. Papillary cancer is the most common thyroid cancer (70-80%), followed by follicular (10-15%). Anaplastic thyroid malignancies are rare (<5%) Both sporadic and hereditary varieties of MTC arise from parafollicular C cells, which make calcitonin. MTCs also make CEA, which, while less sensitive than serum calcitonin as a marker of tumor presence, exhibits less minute to minute variability, and therefore may serve as a useful indicator of tumor mass. Neither differentiates between inherited and sporadic forms. Mutations in RET proto-oncogene are responsible for inherited MTC through altered expression of a mutated receptor tyrosine kinase protein, RET. Hereditary MTC is inherited as an autosomal dominant trait and early ppx thyroidectomy is curative. The specific RET mutation will guide the timing of total thyroidectomy in children and may indicated total thyroidectom as early as 6 months of age. Up to 20% of pts with MTC harbor distant mets at the time of dx and routine central node dissection within the anterior triangle in the center of the neck (level 6) should be performed at the time of total thyroidectomy

Answer 372

E Sx is the primary tx of pheo and paraganglioma, and lap surgery is now the technique of 1st choice for resection. Decr postop morbidity, hosp stay and expense compared to open. Periop mgmt include preop medical mgmt to block the effects of released catecholamines. Phenoxybenzamine, an alpha adrenoreceptor blocker, is most commonly used for preop control of bp. Drug is initially administered at a dose of 10-20 mg PO BID. Alternative include CCB and selective competitive alpha 1 blocking agents, terazosin and doxazosin that have a shorter half life and lower the risk of post op hypotension. A beta blocker may be used for preop control of tachyarrhythmias or angina. Loss of beta adrenergic mediated vasodilation with unopposed catecholamine induced vasoconstriction can result in dangerous incr in bp. Therefore beta blocker should never be used without first blocking alph adrenergic mediated vasoconstriction. Volume contraction assoc with chronic vasoconstriction can be seen in pts with pheo and paraganglioma. Therefore preop volume expansion achieved by saline infusion of incr water intake is recommended to reduce postop hypotension. INtraop bp monitoring with arterial line is mandatory and acute changes in bp during tumor manipulation and resection requie intensive anesthesia input and mgmt. B/C only a unilat adrenalectomy is being done, preop use of steroids is not necessary

Answer 373

B Tumor recurrence after total thyroidectomy has been assoc with several RF including pathologic type and differentiation, tumor size >4 cm, tumor extension beyond the thyroid capsule, nodal or distant mets, age >45, and male High preop thyroglobulin levels are assoc with a spectrum of thyroid pathology, and as such, are variably predictive when attempting to distinguish benign and malignant in the face of nondiagnostic FNA. Thyroglobulin is among the msot sensitive biomarkers of post op disease recurrence and progression, evidence that high preop values are predictive of future recurrence after thyroid resection is lacking. Value in preop thyroglobulin lies in detecting those pts with differentiated thyroid cancer in whom thyroglobulin cannot be detected. Such pts are either unable to produce thyroglobulin or have antibodies to the protein, making serial postop levels unreliable as a marker of recurrent disease.

Answer 374

C All pts with biochemically confirmed PHPT who have specific symptoms or signs of their disease should underogo sx tx. Asympt PHPT is defined as hyperparathyroidism that lacks specific symptoms or signs traditionally assoc with hypercalcemia or parathyroid hormone excess. Medical monitoring rather than sx is appropriate. Threshold value for calcium, above which surgery is appropriate is 1 mg/dL above the upper limit of N. Hypercalciuria in the absence of renal stones or nephrolithiasis is no longer regarded as indication of parathyroid sx. Presence of hypercalciuira >400mg/dL is not considered to be an indication for sx. A GFR <60 mL/min defines stage 3 level of renal insufficiency. Although pts may have reached that level of renal fcn due to age or comorbidity and not due to PHPT, it is regarded by many as a level of concern and indication of sx. Sx is indicated in peri- or postmenopausal women and in men at least 50 yrs who have a T score of -2.5 of less at any site on the bone densiometer. Sx is also indicated for premenopausal women and men <50 yrs with a Z score of -2.5 of less on the bone densiometer. Age <50 continues to be a guideline for sx with evidence supporting a greater risk of complications of PHPT in these individuals over time in those older than 50 yrs

Answer 375

A Myxedema coma is the most extreme fomr of hypothyroidism. Unless rapidly dx and tx, mortality may be as high as 60%. Myxedema coma occurs most commonly in elderly female pts with a hx of hypothyroidism and commonly follows a precipitating event such as major surgery. Other events incl cold exposure, trauma, stroke, heart failure and volume loss Pts develop somnolence, altered mental status, bradycardia, hypothermia, and hypotension. Assoc lab abN may incl elevated TSH, low or undetectable FT$, hyponatremia, elevated creatine phosphokinase, elevated LDH, and acidosis. Tx include mechanical ventilation for airway protection in the obtunded pt, crystalloid resusc for volume depletion and possibly hemodynamic support with vasopressors and thyroid hormone replacement. Hydrocortisone is indicated b/c up to 10% of pts will have coexisting adrenal insufficiency. In addition, hydrocortisone should be given before thyroid hormone replacement b/c thyroid hormone may actually incr cortisol clearance, precipitating adrenal insufficiency. Passive warming is indicated and include covering the pt wiht blankets and keeping the pt in a warm room. Active rewarming should be avoided b/c in incr O2 consumption and promotes hypotension with circulatory collapse by causing peripheral vasodilatation. Active rewarming is indicated at core temp <28 C b/c of risk of ventricular fibrillation.

Answer 376

1. A 2. C 3. A 4. B PHPT is the most common cause of hypercalcemia. Dx is based on an elevated serum calcium and elevated intact PTH. Pts with PHPT also present with a low/lowN phosphate and can have S&S such as fatigue, urinary freq, kidney stones, osteroporosis, constipation, and bone/joint pain. One dx is made, Tc99m scanning is helpful to localize parathyroid adenoma and to plan sx. Patients with hypercalcemia of malignancy will have elevated calcium level but will have an undetectable intact PTH level and an elevated phosphate. Hypercalcemia is cause by bone resoprtion from metastatic tumor deposits, which can lead to osteoporosis.

Answer 377

1. C 2. C 3. B Several conditions that cause thyroid enlargement are caused by autoimmune processes or inflammatory conditions that have specific inflam markers that may be helpful in dx. Ddx includ categories of autoimmune mediated, compensatory, and inflammatory conditions. Compensatory condition, such as iodine deficiency or hormone or receptor defects, generally lack specific markers. Autoimmune conditions such as Hashimoto's thyroiditis, Graves disease and colloid goiter are more likely to have positive markers. Exception is simpe colloid goiter. Although etiology may be an autoimmune process, thyroid antibody titer are N and patient is generally euthyroid Hashimoto thyroidits is a common cause for diffuse thyroid enlargement, occurring most freq in female adolescents. In this condition, CD4 T cells may be activated against thyroid antigens and recruit cytotoxic CD8 T cells, which kill thyroid cells, leading to hypothyroidism. Initially euthyroid, many children progress to become hypothyroid. The thyroid gland is usually a pebbly or galndular consistency and may be mildly tender. 95% of pts with Hashimoto's thyroiditis have elevated antithyroid microsomal antibodies or anithyroid peroxidase antibodies. Plasma thyroid hormones levels are normal or low, and TSH levels are generally elevated. Subacute (de Quervain) thyroiditis is a viral inflam of the thyroid gland. More common in adults. Thyroid becomes swollen, painful and tender. Mild thyrotoxicosis may result from injury to the thyroid follicles with release of thyroid hormone into circulation. Tx is symptomatic and consists of NSAIDS or steroids. Not autoimmune and therefore markers are neg Graves' disease of diffuse toxic goiter is an autoimmune disease caused by the presence of immunoglobulins of the igG class agains components of the thyroid plasma membrance including the TSH receptor. These autoantibodies stimulate the thyroid follicles to incr iodide uptake and cAMP production and induce the production and secretion of incr thyroid hormone. TSH receptor antibodies are present in >95% of pts with active Graves. It is possible that infection may elicit the production of antibodies that react to the TSH receptor. Although the basic pathogenesis of Graves is undersood, no generally successful methods are available to correct the immunologic defect. Current tx incl antithyroid meds, radioactive iodine ablation or surgical resection Hypothyroidsm may resent from a defect anywhere in the hypothalamic-pituitary-thyroid axis and is rarely tx surgically. ~90% of ped hypothyroid is congenital anddetected by neonatal screening programs. Condition results from dysgenesis of the thyroid gland. 2/3 of these infants have a rudimentary gland, and complete absence of thyroid tissue noted in the remainder. The rudimentary gland may also be ectopic and located at the base of the tongue. Thyroid replacement therapy is required. There are no specific markers.

Answer 378

B Ct scan of abdo after the dx of colon cancer is common. Having a basic understanding of the likely liver abN seen and recognizing those most likely of clinical concern is important Hemangioma are the most common benign hepatic tumor. On contrast enhanced CT, they have a characteristic sequential opacification beginning at the periphery of the lesion and proceeding towards the center. FNH accounts for 8% of benign hepatic tumors and has a characteristic central scar in 50% of cases. Isodense on CT and with contrast enhancement shows a high intensity arterial phase; central artery in 20-30% of cases. Will have irreg borders in contrast with a hepatic hemangioma. Hepatic adenoma and HCC may be difficult to distinguish radiographically. Both have high arterial phase enhancement and delayed washout with a surrounding capsule. Adenomas typically occur in setting of OCPs or anabolic steroid use and HCC are highly correlated with cirrhosis. Hepatic CRC mets have a low attenuation compared with surrounding parenchyma during portal phase enhancement.

Answer 379

D Dx of acute chole. Typical mgmt would be lap chole however; this patient has 2 contraindications to OR at this time. First is duration of symptoms, which has been assoc with incr conversion and complication rates likely related to the progression of inflammatory response. Second is pts's perioperative risk. She has recently suffered an MI , which incr her periop morbidity and mortality. B/C this pt does not have evidence of biliary obstruction, an ERCP or perc transhepatic biliary tube would not resolve her process. Cholecystostomy tube under local can reliably decompress the obstructed gb with resolution of symp in >90% of pts. Subsequent mgmt of tube remains controversial, with some studies suggesting that it may be used as definitive therapy in 40% of pts. Tube removal after several wks has a low recurrence rate with follow up of 1-2 yrs. For those in whom cholecystectomy is being entertained, their RF should be modified. if possible before OR.

Answer 380

C Ogilvie syndrome is characterized by massive colonic dilation in the absence of mechanical obstruction. Conservative mgmt with NPO, NG tube placement, IV fluid hydration, electrolyte correction, and removal of contributing meds (narcotics, anticholinergics, CCB) is the initial tx of choice. Majority will resolve with these measures. Serial abdo exams and daily plain AXRs allow close monitoring for improvement or failure of conservative therapy. Failure of conservative therapy is generally defined as cecal diameter >12 cm, distension for >6 days, or failure to resolve with 24-48 hrs of conservative therapy. If there is no evidence of peritonitis or ischemia, neostigmine is the tx if choice after failure of conservative therapy. Neostigmine shown in RCT to improve the abdo distension assoc with Ogilvie compared with placebo. It is a reversible acetylcholinesterase inhibitor that indirectly stimulated muscarininc receptors, enhancing colonic motor activity. Recommended dose is 2 mg IV over 3--5 minutes. Not recommended if there is concern for ischemia or perforation or in the presence of pregnancy, severe active bronchospasm, cardiac arrhythmias or renal failure. Median time to response is 4 mins. If pts do not respond within 3 hrs, dose can be repeated. Recurrence after neostigmine is 11%. Caution during administration is warranted b/c up to 20% of pts have symptomatic bradycardia during administration. The pt should be kept supine and have continuous cardiac monitoring during administration and for 15-30 mins after the dose. NG decompression during neostigmine used is not mandatory. Toxicities from neostigmine are tx with atropine

Answer 381

E Recommended therapy after failure of conservative or neostigmine therapy is colonoscopic decompression. However, when there is concern for ischemia or peritonitis, as in this pt, surgical intervention is appropriate. Risk of perf with decompression colonoscopy in pts with Ogilvies is 3%. Unknow whether this risk is higher in the presence of ischemia. Primary risks related to incr morbidity and mortality in this pt population are ischemia or perforation. Spontaneous perf rate is reported as 3-15% in pts with Ogilvie's. Mortality is 40% when ischmie or perf is present. Risk of perf and ischemia incr with cecal diameter >12 cm. and no cases of perf were reported in large retrospective series when the diameter was <12 cm. Risk of ischemia and perforation incr with incr duration of distension, incr with duration > 6 days. Mean duration of distension in pts who perf'ed was 6 days compared with 2 days in those who did not perf. A 2x incr mortality occurred when the cecal diameter was >14 cm and a 5x incr in mortality accompanied a delay in decompression for >7 days. When ischemia, peritonitis or perf is suspected or present, exp lap or laparoscopy is indicated to assess the viability of the bowel and allow for definitive therapy. At time of OR if viable bowel is present, tx of choice is a surgically placed decompressive cecostomy tube. If ischemic or perfed colon is present, resection determined by the extent/location of the ischemia/perf is appropriate.

Answer 382

C Early gb carcinoma is an uncommon incidental finding in chole speciments, with an estimated 0.3-1% harboring carcinoma. Far more common than nonincidentally discovered gb carcinomas. Pt has a T1 tumor. T1 tumors are divided into T1a when tumor invades the lamina propria but not the muscular layer and T1b when tumor invades through the lamina propria into, but not through, the underlying muscular layer. Recommended tx for pts with T1a tumors is simple chole when the specimen margins are neg. The cure rate for T1a tumors tx with simple chole approaches 100%. Thus additional surgery, systemic chemo or chemorads are not indicated. Although somewhat controversial, the current recommendation for pts with T1b tumors is reexcision of the gb fossa to include a limited hepatectomy and portal lymphadenectomy. This is based on the finding of residual disease in the liver gb fossa in 10% of pts and nodal met incidence of 10-20%. Likewise for pts with T2 tumors (invasion into perimuscular connective tissue, no extension beyond serosa or into liver) or T3 tumors (tumor perforates the seroa and/or directly invades the liver or 1 other adjacent organ) a radical or extended chole is indicated. This means a resection that include a limited hepatectomy and portal lymphadenectomy to encompass the tumor and achieve neg margins. Before definitive sx, the pts should be restaged with abdo CT or MRI and chest imaging to determine the extent of liver and surrounding organ involvement before laparotomy, b/c the riskof peritoneal diseasae is high in pts with gb carcinoma

Answer 383

C Focus for resection is to leave no residual disease while maintaining sufficient hepatic volume and function. Criteria are as follows: 1) Ability to completely resect all disease (R0) at both intra and extrahepatic sites 2) Ability to spare at least 2 adjacent liver segments 3) Ability to preserve adequate vascular inflow and outflow to these segments as well as biliary drainage 4) Ability to leave a sufficient volume of liver (FLR) post op, typically at least 20% of the total estimated liver volume for N parenchyma or at least 30% for a patient receiving significant chemo or having an otherwise injured liver (steatosis, hepatitis but not cirrhosis). Number, location or bilaterally of the liver mets are no longer absolute or relatic contraindications to hepatic resection, as long as the surgeon can acheive complete excision while leaving a sufficient FLR. Survival is not assoc with the width of the resection margin, as long as it is microscopically neg. In the past, extrahepatic disease was an absolute contraindication to hepatic resection for pts with CRC liver mets. This is no longer the case, as complete resection of pulmonary and liver mets is assoc with 5 yr survival rates >30%. Prognosis after resection of lung and liver mets does not appear to be affected by synchronous vs metachronous presentation. Hepatic hilar LN mets also were a contraindication to resection in the past. More recent studies show that LN limited to the hepatoduodenal ligament and not involving the common hepatic artery/celial/periaortic LNs show a 38% 5 yr survival after heaptectomy and lymphadenectomy, compared with 0% when the other LN listed are involved. Thus, hepatoduodenal LN involvement is no longer a contraindication to hepatic resection Untx primary colon or rectal ca and resectable hep mets are not a contraindication to potentially curative resection. Several studies support simultaneous resection of synchronous disease in appropriately selected pts, allowing a single OR for tx of their disease. No incr in morbidity or mortality with a simultaneous operative approach. When a pt with otherwise resectable liver met are predicted to have FLR that is too small to allow safe resection based on CT or MRI volumetry, they may be eligible for preop PV embolizaion. This involves percutaneous cannulation of the R or L portal vein followed by introduction of embolc material into the vein. This allows embolizaion of the portal vein on the side proposed for resection. Result is contralat hypertrophy (FLR) over a 3-4 week period. Remeasurement of the FLR i done by CT or MRI volumetry; if sufficient hypertrophy has occurred, then resection can be undertaken.

Answer 384

B Presents with classic symp and signs of acute appy. Avoiding a CT is cost effective and avoids radiation exposure in this pediatric pt. Serial exam with or without IV abx in this setting of focal peritoneal signs. Meckel scans or repeat US will likely incr the cost of crae, delay appy, and possibly incr morbidity for this pt. Alvarado score may be used in the decision making process (RLQ +2, Rebound +1, Temp >37.3 +1, Migration of pain to RLQ +1, Anorexia +1, N/V +1, WBC > = 10 +1, Left shift +1). Score of 4-6 ==> CT, Score of at least 7==> surgery consult

Answer 385

D Shift in mgmt of pilonidal diseas occured during WWII. Solider hospitalized up to 55 days b/c of open excision and healing by secondary intention. Wide excision and flap closure has evolved as the most expedient tx of complex pilonidal disease leading to early complete healing with very low recurrence rates. Karydakis, Limberg and Bascom flaps are all excellent choices for complex or recurrent pilonidal disease Vacuum assisted closure is complex in this location and inconvenient to the pt and therefore, not a good choice. Repeat incision and packing or healing by secondary intention works very well with low recurrence rates but involves prolonged treatment and time off work and is not a good first choice. Wide excision to the presacral fascia with primary closure is not advised b/c this unnecessarily removes an excessive amt of fatty tissue, does not obliterate the cleft, and results in excessive tension on a suture line, which remains in the midline and prone to dehiscence.

Answer 386

B Hx, exam and Ct are consistent with dx of caroli disease. Given its anatomic location, the lesion is amenable to nonanatomic resection and dose not required extended R hepatectomy. Caroli disease is a congenital disorder of the hepatobiliary tree characterized by multifocal segmental dilation of the intrahepatic bile ducts. Sporadic phenotypic typically involves a single lobe and the fibrous phenotype may involve the entire liver and may be assoc with chronic hepatic fibrosis, choledochal cyst and PCKD. 60-80% of pts transplanted for Caroli disease have PCKD. Present with abdo pain, cholangits, or intrahepatic abscess. Interstingly, some pts with undx Carolic disease will undergo chole based on their symp and will have postop cholangitis, sometimes years later that leads to dx. Incr risk of intrahepatic malignant tumors, particularly cholangioca. Caroli confined to one lobe, either partial hepatectomy or nonanatomic resection is the preferred surgical mgmt. In pts with diffuse Caroli disease, orthotopic liver transplant remains a viable tx option. Hepatic hydatid typically demonstrates a septated, multiloculated cyst with peripheral calcifications and daughter cysts in the periphery. Tx of localized heaptic hydatid cyst disease with PO albendazole and percutaneous puncture, aspiration, injection of hypertonic saline or alcohol and reaspiration of the cyst (PAIR).

Answer 387

E Most common emergency procedure performed worldwide. >75% of adult appys are performed laparoscopically. Pts tx with lap appy are less likely to experience an overall morbidity compared with an open approach. Compared with open appy, pts undergoing lap appy have lower rates of SSI. Other demonstrated benefits of lap appy incl a shorter length of hospital stay, reduced overal morbidity (in particular, wound disruption, unplanned return to OR, sepsis, adn septic shock). reduced OR time, and more rapid return to work and activity compared with an open approach. Some studies show incr risk of organ space surgical site infection with lap appy among pts with complicated appendicitis.

Answer 388

D ITP is na organ specific autoimmune disorder in which low levels of plasma throbopoietin (TPO) contribute to the observed thrombocytopenia. Tx strategies are directed at removal of the specific organ (spleen), general immunosuppression (steroids, immunoglobulin, rituximba), and augmenting thrombopoesis with TPO mimetics (eltrobopag) 1st line for ITP is corticosteroids, augmented with immunoglobulin, if necessary. There is a chance of spontaneous recovery during the first 12 months of dx, although this chance is highest in the first 3 months after dx. For this reason, second line therapies, including splenectomy and rituximab are recommended only if there is little or no response after corticosteroi tx and the pts continues to have significant bleeding. Failure rate after sx may be as high as 28% at 5 yrs. TPO mimetics are considered second or thrid line agents. Produce a consistent short term incr in platelet count but have significant side effects and do not provide a durable response.

Answer 389

D Pt has acute pancreatitis, without man markers or indicator of severe disease. She is tachy with a sl narrowed pulse pressure but she has no indication of organ failure. APACHE II and serum hematocrit are the most helpful in distinguishing mild from severe pancreatitis at adm. Ranson criteria at adm adn 48 hrs later also indicate the severity of disease. Most pts with mild pancreatitis resolve without sequelae; in the absence of organ failure, the mortality should be zero. Determining hte etiology of pancreatitis , most easily done with U/S, is important, b/c 30-60% of pts with a biliary etiology will suffer a subsequent complication of biliary disease within 3 months if they do not undergo cholecystectomy. ERCP reduces complications in pts with severe acute biliary pancreatitis without affecting overall mortality and dose not decr complications in those with mild disease. Perc aspiration of peripancreatic fluid should be performed in pts with panc necrosis in hwo infected necrosis is suspected. Broad specturm abx are reserved for pts in whom infected necrosis is suspected or confirmed and should be instituted along with drainage or debridement using either an open or MIS approach. Continuation of abx is not indicated in the absence of documented infection. Pt is not malnourished and is unliekly to required TPN if her condition does not worsen. If she does develop severe disease, enteral nutrition is preferred.

Answer 390

E Cecal bascule is a type of cecal volvulus. 2 variants based on the character of the cecal twisting: axial torsion type and the cecal bascule type. In axial torsion, cecum twists in the axial plane, rotating around its long axis. With the bascule, the cecum folds anteriorly and upward without torsion. Typically occurs at the level of the bands or adhesions that run across the asc colon. During embryogenesis, cecum assums its N position in the RLQ through rotation of the originally L sided colon with subsequent descent from the subhepatic to the R iliac fossa. Becomes fixed to the R RP. Failure of fixation or malrotation of the bowel creates a mobile cecal segment capable of volvulus. High index of suspicion is necessary to dx this condition early and prevent the colonic closed loop obstruction from progressing to vasc compromise and subsequent gangrene and perf. Exp lap is required for definitive tx of cecal bascule causing complete obstruction. If cecum is viable, it should be detorsed and fixed in position by cecopexy or tube cecostomy, although recurrence can approach 10%, Alternatively, cecal resection can be undertaken. Prevents any recurrence but mortality rates are higher. Cecal volvulus is assoc with a higherrate of ischemia than volvulus involving other colonic segments. Colonoscopic decompression of a cecal volvulus is a challenge in unprepped colon and with this degree of intestinal obstruction, exp lap is indicated to r/o cecal ischemia.

Answer 391

A Nearly 50% of CRC pts will develop liver mets during the course of their disease, with half having hep mets at the time of primary dx and the other half developing metachronous disease. Hepatic resection remains the best tx option for pts with CRC liver mets, with reported 5 yr survival rates of 28-41%. Simultaneous crc resection and minor hepatectomy, defined as resexn of <3 hepatic segments, is done safely with no differences in mortality, severe morbidity, hepatic related morbidity, intraop blood loss of freq of blood transfusion compared with minor hepatic resexn alone. Although regional LN involvement identified at the time of hepatic resection remains a generally poor prognostic factor, selected pts with such nodal involvement benefit from multimodality tx strategy that includes chemo, followed by surgical resexn of the CRC mets and regional LN disease. Hepatatectomy combined with lymphadenectomy may offer pts with simultaneous regional LN involvement a 5 yr survival rate of 18% with no operative mortality. Fluoropyridine hepatic arterial infusion therapy is not assoc with anOS advantage compared with fluoropyrimidine based systemic chemo. Systemic chemo regimens (combining 5 FU with oxaliplatin or irinotecan) obtain tumor response rates similar to or even higher than those observed with fluoropyrimidine based hepatic arterial infusion therapy.

Answer 392

A Liver cell adenoma is increasingly seen due to the widespread use of estrogen based OCPs. It is often dx as an incidental finding in asymp pts. Spontaneous bleeding is a well recognized complication that is often the cause of pain (20-40%), particularly when the lesion is >5cm. Spontaneous bleeding is assoc with an 8% risk of death. Another serious complication is the risk of malignant transformation in approx 5% of pts. Phenotype/genotype of hepatic adenomas is an accurate predictor of malignant changes. This is particularly true in the present of beta catenin mutation. Although liver cell adenoma are mainly observed in women, the presence of androgen exposure independently influences HCC progression. This reflects a male predominance among malignant hepatic adenomas observed in the context of glycogen storage disease or fanconi anemia. Liver transplant is reported for the tx of solitary giant adenoma. However, improvements in surgical technique and perioperative mgmt have reduced postop morbidity after liver resexn; the mortality rate is approx 1%, even after major hepatectomies. Surgical tx is therefore the tx of choice for solitary liver cell adenoma >5 cm or complicated by hemorrhage or malignant transformation and liver transplant should be abandoned

Answer 393

B Choledochal cysts are either single or multiple dilitations of the intrahepatic or extrahepatic biliary tree. Most common presentation is nonspecific abdo pain. If left un tx, cause morbidity and mortality from recurrent cholangitis, pancreatitis, liver absecesses or cholangioca. Mgmt depends on type of cyst Pt with choledochal cyst is first tx for sepsis and prancreatitis. ERCP or MRCP to image the biliary tree after stabilization. Determine the type of cyst. Single stage sx (cyst resection, chole and Roux en y hepaticojej) is preferred and assoc with acceptable morbidity and mortlaity. Internal drainage procedures have success of 30%, risk of post op malignancy is 30%, mortality 11% and >50% require reoperation.

Answer 394

A Primary Budd Chiari syndrome is a rare thromboembolic d/o of hepatic veins/IVC leading to postsinusoidal portal HTN, massive ascites, hepatomegaly, and, in severe cases, liver failure. Stenosis of the vein can be found at the site of thrombosis. In Western countires, it typically occurs in young women, whereas in Asia, it has no gener predilection and typically presents in middle aged pts. Prothrombotic states, such as myeloproliferative d/o, OCPs, and coagulopathies, are known RF. Pts typically present with ascites and liver failure several wks to months after a prodrome of RUQ pain, postbrandial bloating and and anorexia. Dx is made with Doppler U?S, CT or MRI Surgical shunt was a popular traditional therapy for this disorder, now superceded by less invasive interventions. Current tx algorithms recommend immediate anticoagulation, followed by percutaneous angioplasty +/- stenting, especially in the third of pts harboring short venous stenoses. If do not improve, TIPS. If fulminant liver failure, liver transplant

Answer 395

E Ventral hernia is one of hte most common procedures. Tension free repair using mesh has become the accepted practice for repair of such hernias. Mesh infection remains a dreaded complication b.c explantation is required. Mesh infection rates approach 10%. Infection was the most common reason for explantation (70%) followed by SBO and pain. RF incl use of PTFE via open approach, concomitant same site abdo procedure, post op surgical site infection, and development of post op EC fistula. Mesh position in relation to fascia, BMI and operative approach were not independent risk factors. Staph aureus is the msot common isolate in mesh infections. Other less common organisms include Streptococcue, Enterobacteriaceae, and anaerobes. Salvage of mesh can be considered in the presence of superficial wound infection that spare the deep tissues. Broad spectrum ABX coverage with observation is initiated in these circimstances; wound opening and irrigation is then performed if necessary. Presence of continued supparation after such interventions, however, requires mesh explantation.

Answer 396

1. B 2. C 3. A 4. C Biliary strictures are dividede into benign and malignant causes. Cause generally affects the choice of tx. Benign causes are related to stricture formation from and injury (such as during cholecystectomy), prior anast, choledocholithiasis, extraluminal compression (such as Mirrizi syndrome), ischemic injury, ampullary stenosis, or chronic pancreatitis. Malignant causes include cholangioca, pancreatic tumors, ampullary tumors, duodenal carcinoma, HCC, and metastatic disease Tx of biliary strictures depends on underlying pathology. Pts who are good surgical risk with malignant stricture should undergo surgical resection for localize disease. Choledochoduodenostomy is done in side to side fashion. It is indicated for benign biliary stricture of the distal 1/3 of the CBD. Avoided in malignant disease b/c of potential of obstruction from the cancer. Although "sump syndrome" (i.e. debris accumulating in the distal CBD) was considered a reason to avoid choledochoduodenostomy, the incidence of this complication appears low. Roux-en-Y choledochojejunostomy is the most commonly used form of surgical biliary bypass. It is indicated for both benign and malignant biliary strictures. Metallic wall stents were initially self explandable and uncovered. Designed for palliation of pts with unresectable or met cancers involved the CBD. Stents were not good choiced for benign biliary stricturs b/c of reactive tissue hyperplasia leading to poor long term patency. Conversely, covered, metallic wall stents may be useful for benign strictures. Plastic stents are relatively small stents intended for temporary use. Can be used to allevaite obstruction and reverse jaundice in both benign and malignant biliary strictures.

Answer 397

1. C 2. D 3. D 4. A Pheos are neuroendocrine tumors of the adrenalgald that secrete catecholamines. Typically present with HTN, diphoresis, palpitations and headaches. CT or MRI will reveal a unilat adrenal mass whereas 10% of pheos are bilat. MEN1 is an autosomal dominant syndrome with >95% penetrance of at least 1 clinical manifestation by age 40. It is caused by germline mutations in the menin gene. Tumors include hyperparathyroidism (>95%), neuroendocrine tumors of the pan (30-80%), anterior pituitary (20-65%), nonfunctioining adrenal adenomas or masses (5-41%) foregut carcinoids (2-8%) and thyroid neoplasna (8-27%). Other common clinical findings include multiple lipomas, facial angiofibromas, and collagenomas MEN 2 is an autosomal dominant syndrome cause by germline mutations in RETproto-oncogene. Subdivided into 2 entitis. MEN2A consists of MTC (>95%), pheo (50%), and hyperparathyroidism (25%). Other more uncommon manifestations inlcude Hirschsprung diseas and cutaneous lichen amylodosis. MEN2B is characterized by MTC (100%), pheo (50%), marfinoid habitus, mucosal neuromas on the tongue and lips and diffuse ganglioneuromas of the GI tract 2 most common causes of hyperalsdosteronism are a unilateral adreanl adenoma (Conn's) and bilat adrenal hyperplasia. Present with HTN and hypokalemia. Tx by resection, usually with lap adrenalectomy, whereas bilar adrenal hyperplasia is initially managed with medical tx. Differentiating aldosteronoma from bilat adrenal hyperplasia is critical for successful tx. CT or MRI can usually localize an aldosteronoma revealing an adrenal mass but adrenal venous sampling for aldosterone is considered the gold standard for determining whether an aldosteronoma of hyperplasia is the etiology of the hyperaldosteronism.

Answer 398

1. B 2. A 3. D Hepatic amebic abscess caused by entamoeba histolytica, which is endemic in Mexico, india, africa and parts of central and south america. Cysts are ingested via a feco-oral route, with humans as principal host. Infection is usually caused by contact with a cyst passing human carrier. Cysts pass into the intesting adn release a trophozoite, whih then invades the colonic mucosa and eventually travels through the portal venous system to the liver. Hepatic amebic abscess is caused by liquefaction necrosis Cavity is full of blood and liquified liver tissue and is described as anchovy sauce. Glisson's capsule is resistant to amebic destruction, amebic abscesses tend to abut the liver capsule. Pts tend to be hispanic men, 20-40 yrs, wholive in or traveled to an endemic area. 10:1 90% of pts. Therapeutic needle aspiration has been added to metronidazole tx without much benefit Hydatid cyst is caused by 1 of 3 species of echinococcus Occurs in areas of the whorl where sheep grazing is common. Dogs are definitive host; adult echinococcus tapeworm resides in dog's ileum nad depositis eggs into feces. Sheep are an intermediate host and human are an accidental intermediate host. No human-human transmission, and humans are an end stage fo the parasite. Parasite embryo releases on oncosphere into the human duodenum, where it penetrates the mucosa and enters the blood stream travelling to the liver. Hydatid cyst then develops and can give rise to other daughter cysts. Cyst wall can become calcified. Most common symptoms are abdo pain, n/v. Exam reveals hepatomegaly.. U/S or CT shows a well circumscribed cyst sometimes with budding daughter cysts. Calcifications are highly suggestive of a hydatid cyst. Tx is primarily surgical and can be difficult b/c free rupture of cyst into peritoneal cavity can result in anaphylaxis. Abdo is explored, liver mobilized, and cyst exposed and isolated from peritoneal cavity with packs. Cyst is then aspirated with a closed suction system and flushed with a scolicidal agent such as hypertonic saline. Cyst can then be excised or marsupialized. Studies describe successful puncture, aspiration, injection, and reaspiration (PAIR) therapy.

Answer 399

1. A 2. B 3. C 4. D Lumbar hernias are rare and subdivided into hernias of the superior lumbar space of the inferior lumbar space. Superior lumbar space is also called the Grynfeltt (internal oblique, erector spinae and 12th rib). Inferior lumbar space is known as Petit triangle (ext oblique, internal oblique and iliac crest) and protrusion through that space is known as Petit hernia. Grynfellt is the more cmoon of the 2. Lumber hernias can be congenital or acquired Spigelian hernias most commonly occur at or below the arcuate line along the spigelian fascia (seilunar line). Tend of occur at the point where the semilunar and arcuate lines meet, b/c at this point, all the fibers of the transversus abdominis muscle pass in front of the rectus muscle. Most are idiopathic and believed to be acquired. Often intramural and expand under the external oblique muscule, making palpation difficult One of the most common symptoms in obturator hernais is pain extneding fown the medial aspect of the thigh to the knee. Known as Howship Romberg sign or obturator neuralgia Perineal hernia sare rare iatrogenic hernias that may occur after OR such as AP, cystourethrectomy, or pelvic exent. Factors that may contribute to the occurence of perineal hernia include failure to close primarily the defect in the pelvic floor at the time of first OR and occurrence of a deep postop wound infection. Any hernia can be a Richter hernia if the antimesenteric border of the intestine protures into the hernia sac but not to the point of the entire circumference of the intestine.

Answer 400

A Projected annual transition rates from advanced adenomas to CRC strongly increase with age (from 2.6% in age group 55–59 years to 5.6% in age group ⩾80 years among women, and from 2.6% in age group 55–59 years to 5.1% in age group ⩾80 years among men). Projections of 10 year cumulative risk increase from 25.4% at age 55 years to 42.9% at age 80 years in women, and from 25.2% at age 55 years to 39.7% at age 80 years in men.

Answer 401

A Sabiston says abdo pain/obstruction; SBO usually due to desmoplastic reaction, can be intussesception.

Answer 402

C Overall, rectum is most frequently injured! More radiation delivered to pelvis for pelvic malignancy. Rectum is more resistant but more commonly involved. For small bowel, TI most commonly

Answer 403

D SCNA – Small Bowel and Colon Perforations, 2014 Infectious causes of intestinal perforation are far more common in developing countries and immunocompromised patients. Infectious diseases such as typhoid and tuberculosis are the most common cause of intestinal perforation in developing countries, whereas viral enteritis (particularly cytomegalovirus) is a potential cause of intestinal perforation in the immunocompromised patient. Intestinal perforations caused by infection usually occur in the terminal ileum but viral enteritis may cause right-sided colonic perforations as well. Perforations caused by an infectious cause should be treated with segmental resection of the diseased segment of bowel. Most situations will allow a primary anastomosis but, depending on patient condition, degree of contamination, and integrity of the remaining bowel, exteriorization of the remaining bowel may be considered. For typhoid its conversial whether primary repair or resection is preferred, but generally solitary perforations can be safely managed with primary closure, multiple perforations should have segmental resection.

Answer 404

A vs C Stricturoplasty – not great in D3; ok if peripyloric, 1cm too short, although DCR article 2009 says strictureplasty is effective for duodenal CD in all locations with good safety Balloon dilatation – safe in short (<4cm strictures), perforation risk 2%. Shaw says very unlikely that you could technically do this given location

Answer 405

A Duplications represent mucosa-lined structures that are in continuity with the gastrointestinal tract. Although they can occur at any level in the gastrointestinal tract, duplications are found most commonly in the ileum within the leaves of the mesentery. Duplications may be long and tubular, but usually, they are cystic masses. In all cases, they share a common wall with the intestine. Symptoms associated with enteric duplication cysts include recurrent abdominal pain, emesis from intestinal obstruction, or hematochezia.

Answer 406

A In acute phase early enteral feeding is necessary. Long term is frequent small meals. Calcium supplementation necessary as poor absorption. Up to Date Slow introduction of enteral feeding is indicated once the patient stabilizes. Complex diets are known to enhance greater adaptation than elemental diets; however, elemental diets have a role when intestinal inflammation is present. Continuous tube feeding (exclusively or in conjunction with oral feeding) in the postoperative period has been shown to significantly increase net absorption of lipids, proteins, and energy compared with oral feeding. Continuous feeding is best, but frequent small meals is next/

Answer 407

A 70% close spontaneously, and 70-80% are iatrogenic.

Answer 408

A Some evidence CD is increasing. UC is more common in smokers

Answer 409

C Eye involvement common in UC, but <5% of CD. Eye and skin manifestations respond to colectomy in UC, PSC and arthritis don’t.

Answer 410

D Flagyl causes neuropathy

Answer 411

D 1. Ovarian 2. Melanoma 3. Lung Peritoneal spread: ovary, colon, stomach. Hematogenous: melanoma, lung, breast, cervix UTD Extraluminal involvement of the small bowel is common in the setting of widespread peritoneal carcinomatosis. Erosion through the bowel wall into the lumen can occur, particularly with tumors that have a predilection to involve the peritoneal cavity, such as ovarian, colon, and gastric cancer. Hematogenous spread to the bowel is also possible. In studies in which direct extension from peritoneal metastases was excluded, the most common tumors to hematogenously spread to the small bowel were melanoma, lung, breast, cervix, sarcoma, and colon

Answer 412

A and C UTD Increased risk of radiation enteritis in vascular disease, IBD and collagen-vascular disease. Sabiston: Other factors, including previous abdominal surgeries, preexisting vascular disease, hypertension, diabetes, and adjuvant treatment with certain chemotherapeutic agents, such as 5-fluorouracil, doxorubicin, dactinomycin, and methotrexate, contribute to the development of enteritis after radiation treatments.

Answer 413

D Sabiston & Up to Date: Acquired diverticuli occuring near the ampulla of Vater on medial wall; incidence 2-5% on barium, diverticulitis treated conservatively, only operate for perforation, abscess, or intractable bleeding. Twice as frequent in women. Can cause bacterial overgrowth and diarrhea. Surgery included diverticulectomy with primary (transverse) closure, taking care to not injure ampulla.

Answer 414

B Similar to excessive vomiting from pyloric stenosis. hypokalemic hypochloremic alkalosis due to loss of HCl

Answer 415

D? Initial treatment of intestinal fistulas is medical, including resuscitation, control of sepsis, local control of fistula output, nutritional support, pharmacologic management, and radiologic investigations. The final therapeutic step, if necessary, is definitive surgery to restore gastrointestinal (GI) tract continuity. The procedure involves resection of the intestinal segment, fistula tract, and the adjacent part of the involved structure In the absence of extensive infection or inflammation, primary anastomosis of the divided intestinal segments is done to reestablish GI continuity and repair of the involved structure to maintain function In the presence of extensive infection or inflammation, the divided intestinal segments are exteriorized and the surgical procedure is modulated to allow replacement or maximal preservation of function A staged procedure is performed after the infection and inflammation subsides to reestablish GI continuity and reconstruction of the affected structure

Answer 416

A Adynamic ileus from neurotoxic effects Vincristine - neurotoxic Adriamycin - heart Bleomycin - pulmonary

Answer 417

D Mucosal delamination and dec goblet cells in UC UC pathognomonic feature is crypt abscess, also has decreased goblet cells. CD increased goblet cells, lymphoid aggregates, transmural inflammation, etc.

Answer 418

A This patient has FAP (Gardners), so the only treatment is Whipple (high Spigelman score). For non-FAP ampullary adenomas, consider ampullectomy if comorbid or old vs Whipple, which is better in a fit/young person for survival and recurrence. Stage I & II – surveillance q 3-5years Stage III – surveillance q1-2 years; consider PD Stage IV: PD Many clinicians advocate radical pancreaticoduodenectomy for periampullary duodenal villous adenomas because of the difficulty in making a preoperative diagnosis and in obtaining an adequate resection without sacrificing the ampulla. However, one study found that local submucosal excision produced acceptable long-term results if the tumor did not have areas of invasive cancer; 17 percent recurred after five years of follow-up [89]. Periampullary adenomas containing areas of malignant growth (in situ or invasive) still require radical surgery

Answer 419

Answer key says A (only if the cecum is normla and not inflamed0

Answer 420

A Intestinal obstruction is the most common presentation in adults with Meckel’s diverticula. Diverticulitis, present in 20% of patients with symptomatic Meckel’s diverticula, is associated with a clinical syndrome that is indistinguishable from acute appendicitis. In children, hemorrhage. Perforation is rare

Answer 421

B Not hypovolemic. Probably hypervolemic, oliguric AKI

Answer 422

A According to EAST and WTA guidelines

Answer 423

B Laryngotracheal injury — Some laryngotracheal (LT) injuries are obvious, while others require diagnostic imaging. Multidetector helical CT (MDCT) is the tool used most often to screen for these injuries in stable patients. MDCT provides anatomic detail about laryngeal integrity and is useful when cervical spine immobilization is necessary [54-56]. MDCT provides better images of mineralized cartilage than plain radiographs. Pharyngoesophageal injury — Debate continues about the best management strategy for identifying pharyngoesophageal injuries following penetrating neck injury (PNI). More trauma centers are using a selective approach to surgical exploration. This can delay the detection of esophageal injury and such delays can increase mortality [27]. Furthermore, debate persists about whether esophageal injuries requiring surgery manifest obvious clinical findings [27,69]. Given the potential difficulties in diagnosis and the consequence of delays, many trauma specialists obtain imaging studies to rule out esophageal injury in all cases of nonsuperficial PNI. A multidetector helical CT scan (MDCT) is often the first study obtained because it can detect laryngotracheal, vascular, and esophageal injuries simultaneously and rapidly.

Answer 424

C ``` Up to Date: Blunt Thoracic Aortic Injury ●Type I: Intimal tear ●Type II: Intramural hematoma ●Type III: Pseudoaneurysm ●Type IV: Rupture (eg, periaortic hematoma, free rupture) ``` For Type I injuries (intimal tear), we suggest nonoperative management which consists of aggressive heart rate and blood pressure control, and serial imaging [41]. For patients with Type II, III, and IV injuries, we recommend repair. Without repair, the outcomes of untreated thoracic aortic rupture are poor. While awaiting repair, we aggressively control blood pressure and heart rate. Delayed repair may be appropriate for patients who are hemodynamically stable, particularly if the patient has severe coexistent injuries (see 'Immediate versus delayed repair' below). Delayed repair is only for grade II injuries; early repair required for rupture or pseudoaneurysm (EAST and UTD)

Answer 425

A Decreased sensitivity in obesity. Would not take unstable patient to CT. This may actually be an indication for DPL, but relatively contraindicated in obesity, and would do suprapubic as may have pelvic fracture/hematoma. When FAST is negative, the suspicion for intra-abdominal hemorrhage remains high, and the patient remains too unstable to be safely taken to the CT scanner, DPA may quickly provide an answer. It is the aspiration portion of the diagnostic peritoneal lavage without the lavage. When performed percutaneously, DPA is rapid and safe, and it does not have the high sensitivity of DPL.

Answer 426

B Emergent tracheostomy is indicated in patients with laryngotracheal separation or laryngeal fractures, in whom cricothyroidotomy may cause further damage or result in complete loss Emergent tracheostomy is indicated in patients with laryngotracheal ofthe airway. This procedure is best performed in the OR where there is optimal lighting and availability of more equipment (e.g., sternal saw). In these cases, often after a “clothesline”injury, direct visualization and instrumentation of the trachea usually is done through the traumatic anterior neck defect or after a generous collar skin incision (Fig. 7-2). If the trachea is completely transected, a nonpenetrating clamp should be placed on the distal aspect to prevent tracheal retraction into the mediastinum; this is particularly important before placement of the endotracheal tube. CONTRAINDICATIONS — There are few absolute contraindications to tracheal intubation. Most involve supraglottic or glottic pathology that precludes placement of an endotracheal tube (ETT) through the glottis or which may be exacerbated by insertion of the ETT or laryngoscope. As an example, blunt trauma to the larynx may cause a laryngeal fracture or disruption of the laryngotracheal junction. In such cases, traction from the laryngoscope blade or pressure from a stylet within an ETT could create a false lumen or complete a partial tear of the trachea [3].

Answer 427

A Tracheobronchial injury; initial managemt is bronch, surgical repair is best.

Answer 428

C Surgery for accessible lesions — For patients without completed hemiplegic deficits, we suggest surgical management for patients with surgically accessible Grade II through Grade V blunt cerebrovascular injuries, in agreement with major trauma society guidelines. However, many blunt cerebrovascular injuries involve the vessel (eg, internal carotid artery) at the base of the skull, and are therefore not surgically accessible. In our experience, only 2 of 700 patients treated with blunt cerebrovascular injury had a surgically-accessible lesion. This experience is shared by others. Thus, inaccessibility precludes direct surgical repair in most patients with blunt cerebrovascular injury. Trauma: Only observation without the administration of anticoagulants is appropriate temporarily in patients with a Grade I–IV injury and an associated traumatic brain injury or solid organ injury. The timing of initiation of anticoagulant therapy in the described patient groups is unclear at this time. It should, however, be based on the presence or absence of neurological findings, the magnitude of the BCVI, and the magnitude of the associated injuries. The use of anticoagulants in this situation is somewhat analogous to the use of the same for prophylaxis against deep venous thrombosis in patients with traumatic brain injuries. In one recent study using early enoxaparin in selected patients with traumatic brain injuries, but without CT exclusion criteria, the safety of this approach was demonstrated.93

Answer 429

A EAST Level 1 1. An admission electrocardiogram (ECG) should be performed on all patients in whom BCI is suspected (no change) Level 2 1. If the admission ECG reveals a new abnormality (arrhythmia, ST changes, ischemia, heart block, and unexplained ST changes), the patient should be admitted for continuous ECG monitoring. For patients with preexisting abnormalities, comparison should be made to a previous ECG to determine need for monitoring (updated). 2. In patients with a normal ECG result and normal troponin I level, BCI is ruled out. The optimal timing of these measurements, however, has yet to be determined. Conversely, patients with normal ECG results but elevated troponin I level should be admitted to a monitored setting (new). 3. For patients with hemodynamic instability or persistent new arrhythmia, an echocardiogram should be obtained. If an optimal transthoracic echocardiogram cannot be performed, the patient should have a transesophageal echocardiogram (updated). 4. The presence of a sternal fracture alone does not predict the presence of BCI and thus should not prompt monitoring in the setting of normal ECG result and troponin I level (moved from Level 3). 5. Creatinine phosphokinase with isoenzyme analysis should not be performed because it is not useful in predicting which patients have or will have complications related to BCI (modified and moved from Level 3). 6. Nuclear medicine studies add little when compared with echocardiography and should not be routinely performed (no change) Level 3 1. Elderly patients with known cardiac disease, unstable patients, and those with an abnormal admission ECG result can safely undergo surgery provided that they are appropriately monitored. Consideration should be given to placement of a pulmonary artery catheter in such cases (no change). 2. Troponin I should be measured routinely for patients with suspected BCI; if elevated, patients should be admitted to a monitored setting and troponin I should be followed up serially, although the optimal timing is unknown (new). 3. Cardiac computed tomography (CT) or magnetic resonance imaging (MRI) can be used to help differentiate acute myocardial infarction (AMI) from BCI in trauma patients with abnormal ECG result, cardiac enzymes, and/or abnormal echo to determine need for cardiac catheterization and/or anticoagulation (new).

Answer 430

A If there’s a detailed CT report that mentions no thickening, stranding, pneumoperitoneum, or mesenteric hematoma, can consider DPL. Needs to be evaluated as unreliable physical exam.

Answer 431

A if stable. B if unstable Rebleed or a pseudoaneurysm

Answer 432

A ABI is the primary adjunct in assessing for extremity vascular injuries, must be >0.9, normally is 1.1. If ABI is <0.9, should go to the OR. Indications for Angiography in Penetrating Extremity Injury - Significant hematoma in proximity to wound with intact distal flow - Multilevel penetration from shotgun blast - Thrill or bruit over injury

Answer 433

D Initial management is BB, but type III BAI requires TEVAR. This patient has only mild TBI, and no risk factors for infection and without severe multisystem trauma, so immediate TEVAR is indicated. Delayed repair is generally better for type II, NOT an option for III/IV.

Answer 434

A Helps with diagnosis, directs thoracotomy laterality

Answer 435

B Destructive colon injuries >50% best treated with resection and anastomosis. In nondestructive injuries, level 1 evidence that ALL can be primarily repaired regardless of other factors (time, transfusion, etc). Also level 1 evidence that primary anastomosis without diversion is safe and in fact reduces abdominal septic complications compared with colostomy. However, for destructive colonic injuries, accepted practice is to divert if peritonitis, 6 or more units transfused, >6 hours from injury.

Answer 436

A Thoracic duct injuries can occur with penetrating injury to Zone I or II on the left side. They are rare and represent less than 1% of all penetrating neck injuries. If identified at the time of surgical exploration by visualizing leaking or welling of milky fluid, ligation is recommended to prevent progression to chylothorax. Most injuries that present later in the form of a chylothorax may be managed with a chest tube and a low-fat diet without the need for surgical ligation. Leaks >1L, or >600mL /24 hrs are unlikely to close with only medical managent. However, surgery is risky due to injury to neurovascular structures trying to dissect out the duct. Trial conservative management; if output high despite maximal measures, then reoperate, but try to avoid the surgical risk.

Answer 437

A MRCP for any blunt pancreatic lac or moderate peripancreatic fluid; if only peripancreatic edema expectant management.

Answer 438

B This grading scale is described as follows: Grade I, luminal irregularity or dissection with a 25% narrowing; Grade II, dissection or intraluminal hematoma with ≥ 25% luminal narrowing, intraluminal thrombus, or raised intimal flap; Grade III, pseudoaneurysm; Grade IV, occlusion; and Grade V, transection with free extravasation. Appropriate treatment is the placement of an endovascular stent for a pseudoaneurysm or intimal lesion and acute balloon occlusion, if needed, followed by coil embolization of an arteriovenous fistula or active hemorrhage. In patients undergoing a cervical exploration for hemorrhage or a suspected injury to the aerodigestive systems, active hemorrhage originating from the posterolateral neck adjacent to the spinal transverse processes is likely from an injured vertebral artery. As proximal ligation of the ipsilateral vertebral artery originating from the second portion of the subclavian artery is unlikely to stop the hemorrhage, packing with bone wax or gauze is commonly utilized and is always successful. Management of vertebral arteries is challenging. If bleeding in the OR, pack with bone wax for control; ligation is technically very difficult and unlikely to control. Management of injuries is primarily medical for Grade I-IV, or endovascular for Grade III/IV. With occlusion of the vertebral artery by the trauma itself or by operative ligation or coil embolization, antegrade thrombosis is a risk in the postoperative/postprocedure period. For this reason, anticoagulation with heparin is appropriate before discharge. Whether long-term anticoagulation is necessary is unclear. When unilateral vertebral artery ligation, packing, or coil occlusion is performed, a mortality of 5–15% expected.122,125 Deaths are invariably due to prehospital exsanguination or an associated injury to the brain.

Answer 439

A Spinal fracture increases suspicion for SB/duodenal injury.

Answer 440

B Want to rule out hemoorhagic shock as reason for hypotension

Answer 441

A Suspect duodenal injury

Answer 442

C Since stabl can repair. Likely too much tissue loss for primary repair If unstable widely drain

Answer 443

B Damage control, resect what is devitalized, reconstruct later. GDA ligation does not give adequate hemostasis.

Answer 444

B Indications for ICP monitoring in TBI are a GCS score ≤8 and an abnormal CT scan showing evidence of mass effect from lesions such as hematomas, contusions, or swelling [75]. ICP monitoring in severe TBI patients with a normal CT scan may be indicated if two of the following features are present: age >40 years; motor posturing; systolic BP <90 mmHg

Answer 445

B Pack then angio

Answer 446

D and A on answer key

Answer 447

C Bile duct injury should be addressed after hemorrhage has been controlled. In the patient who remains in shock and coagulopathic, packing and placement of a Jackson-Pratt drain in the area of biliary injury is adequate until reexploration is performed. In the somewhat more stable patient who is becoming coagulopathic, a small T-tube placed in the injured duct will provide adequate drainage until a formal repair can be accomplished.139With a partial transection of a right or left hepatic duct, insertion of a small T-tube into the common hepatic duct with a long limb traversing the partially transected area even without suturing may provide enough support for full healing.140 For the stable patient definitive repair is preferred at the first operation. Four broad categories of biliary duct injury have been described: (a) avulsion of cystic duct or small laceration, (b) transection without loss of tissue, (c) extensive defect in the wall, and (d) segmental loss of ductal tissue.140 Avulsions and small lacerations in the duct can be repaired primarily with 6-0 polyglycolic suture making sure not to narrow the lumen. A T-tube with a limb under the repair can be used; however, this may be difficult to insert in a patient with a normally small duct. The techniques used to place a T-tube may also devascularize an already compromised duct. Therefore, the authors will not place a T-tube in primary repair. For avulsions in which primary repair may narrow the lumen, a piece of the cystic duct or proximal gallbladder wall can be used for the repair.141 Penetrating injury very occasionally results in a transection of the bile duct without significant tissue loss. In these instances an end-to-end anastomosis can be performed.

Answer 448

D in answer key FAST first; need to hemodynamically stabilize. Aortic injury at this point won’t kill him; delayed repair.

Answer 449

C if findings on a CT | B if in the OR

Answer 450

C in answer key B is a reasonable option since pt is stable

Answer 451

B 1. All hemothoraces, regardless of size, should be considered for drainage (Level 3). 2. Attempt of initial drainage of hemothorax should be with a tube thoracostomy (Level 3). 3. Persistent retained hemothorax, seen on plain ﬁlms, after placement of a thoracostomy tube should be treated with early VATS, not a second chest tube (Level 1). 4. VATS should be done in the ﬁrst 3 days to 7 days of hospitalization to decrease the risk of infection and conversion to thoracotomy (Level 2). 5. Intrapleural thrombolytic may be used to improve drainage of subacute (6-day to 13-day duration) loculated or exudative collections, particularly patients where risks of thoracotomy are signiﬁcant (Level 3). If earlyVATS, if late, thoracotomy

Answer 452

B Less clear in blunt trauma, in which case endovascular repair is reasonable; in penetrating trauma, operate, unless zone I, in which case endovascular.

Answer 453

Answer key says A or C But ER thoracotomy contraindicated in blunt trauma

Answer 454

C ``` Moderate hypothermia (< 32°C) causes platelet sequestration and inhibits the release of platelet factors that are important in the intrinsic clotting pathway. Core temperature often falls insidiously because of (a) exposure at the scene and in the ED, (b) administration of resuscitation fluids stored at ambient temperature, and (c) the presence of shock. The first step is to prevent further heat loss by covering the body (including the head) and infusing warm blood and fluid. Another simple technique is to heat and aerosolize ventilator gases. Active external rewarming with heating blankets and increased room temperature should also be employed. These techniques are not, however, very effective in reversing established hypothermia. Acidosis has greater adverse effects on coagulation status, but the use of bicarbonate in the treatment of systemic acidosis remains controversial. Acidosis in the trauma patient is caused primarily by a rise in lactic acid production secondary to tissue hypoxia and usually resolves when the volume deficit has been corrected ```

Answer 455

C If pericardial window is option, go with that. FAST and TTE are not sensitive for pericardial effusion in setting of hemothorax.

Answer 456

A in answer key | B is also reasonable and more what we do in real life

Answer 457

A or B on answer key Factors previously thought to completely preclude nonoperative management include splenic injury grade, head injury, high Injury Severity Score, degree of hemoperitoneum, age greater than 55 years, number of transfusions, and pooling of contrast or a blush on CT scan. More recent literature has shown that the severity of splenic injury (as suggested by CT grade or degree of hemoperitoneum), a contrast blush seen on CT scan, neurologic status, age greater than 55 years, and/or the presence of associated injuries are no longer contraindications to a trial of nonoperative management

Answer 458

A in answer key but C seems like a better answer Maybe remove packs first? Depends on timing. For liver, don’t remove packs <36 hours as increased mortality. A variant said patient had a VAC – if so, I think the point of the question is that you can still get ACS even with VAC. Abdominal compartment syndrome (ACS) is defined as a sustained IAP > 20 mmHg (with or without an APP < 60 mmHg) that is associated with new organ dysfunction / failure. IAH is graded as follows: Grade I: IAP 12-15 mmHg, Grade II: IAP 16-20 mmHg, Grade III: IAP 21- 25 mmHg, Grade IV: IAP > 25 mmHg Normal cardiac index is >2.6; less can be cardiogenic shock. This patient has ACS, cardiovascular and respiratory compromise. CVP is normally <4mmHg.

Answer 459

D Have to operate because 1) NOM not studied in penetrating injury and 2) need to rule out colon injury. Sounds like perfect patient to salvage spleen.

Answer 460

A Need to rule out FAP/Gardners. Don’t need to re-excise desmoid, medical or radiation only for dificult location, mesenteric, etc. High rate of recurrence regardless. Treatment for abdominal wall desmoid is resection.

Answer 461

D HNPCC/Lynch Syndrome. Amsterdam Criteria: 3-2-1. Complete colonoscopy q 1-2 years startin at age 20-25 in known HNPCC. Proband could be tested for HNPCC genetics, but not children. EGD 3-5 years starting age 30, annual endometrial biopsy, pelvic exam, TV ultrasound, annual urinalyis. Routine screening for breast and prostate.

Answer 462

A Up to Date: Ureteral injury — Repair of ureteral injuries often involves ureteral stenting or advanced surgical repair. The exception to this is the ligation or kinking of a ureter with a suture. In such cases, the suture is removed and the integrity of the ureter is inspected. Cystoscopy is performed to verify ureteral function.

Answer 463

B Cameron: Advanced colon cancers can also involve the ovaries. Oophorectomy is recommended during colon cancer resection if the ovaries look grossly abnormal, are invaded by the primary tumor, or have known metastases. Ovarian metastases develop in less than 15% of women with colon cancer, and prognosis is generally poor. Routine prophylactic oophorectomy is not recommended unless there are pertinent risk factors, such as a history of HNPCC or a breast cancer susceptibility (BRCA) gene mutation. CRC is most common primary for mets to ovary and about 50% are bilateral.

Answer 464

B Right hemicolectomy plus pancreaticoduodenectomy vs partial duodenectomy in treatment of locally advanced right colon cancer invading pancreas and/or only duodenum. Surgical Oncology Volume 23, Issue 2, June 2014, Pages 92–98. Recently, even more case reports and case series described T4 right colon cancers requiring either pancreatic or duodenal resections. Data from these studies provided evidence to support aggressive resections of adjacent organs, including the pancreas, with acceptable morbidity and mortality rates [4]. Partial duodenal wall resection was only associated with poor outcomes when compared to Whipple procedure, perhaps indicating the need for radical resection of the secondarily involved organ to include the lymphatic drainage. For patients with poor general conditions some Authors suggest a partial duodenal resection plus RH, when duodenum only is partially involved by the tumour, with the papilla of Vater free of disease [56],. In case of non-metastatic right LACC, multivisceral resection is actually increasingly advised [67]. Elderly alone, taken apart comorbidities, should not be considered as an absolute contraindication to multivisceral resection, since in selected patients it may give better overall results than more conservative approaches [68].

Answer 465

C Advanced adenoma: early rescoping at 6 months, then 3 years if normal at 6 month followup. Sessile, dysplastic polyp with piecemeal excision is high risk for recurrence. Needs short interval colonoscopy. No colectomy as is non-invasive, but may be required if incomplete resection after 2-3 endoscopic attempts.

Answer 466

B Formal right hemicolectomy is currently recommended for any one of the following: tumors greater than 2 cm in size, invasion at the appendiceal base, evidence of lymphovascular invasion, any invasion of the mesoappendix, mixed histology (goblet cell carcinoids, adenocarcinoids), and intermediate- to high-grade tumors.

Answer 467

A vs. E in answer key. Alternatively, may have to do R hemi if patient is perforated or near obstructing. The post op refer pt to med onc for chemo and surg onc for consideration of HIPEC

Answer 468

A Adverse features: Haggit 4, sessile, high grade, LVI, PNI, tumour budding. For Haggit 1, risk of LN mets is 0%, for 3, 6%, and for 4, up to 27%. ASCRS Practice Guidelines According to current treatment guidelines, the characteristics of malignant polyps that are appropriately treated by endoscopic resection only are: Haggitt levels 1 to 3 (not level 4, which includes all sessile polyps), well-differentiated histology, >2 mm margins, and the absence of tumor budding and lymphovascular invasion.94–96 For malignant polyps that do not meet these criteria, standard care includes referral to a surgeon for the consideration of surgical therapy. There is currently a lack of data regarding the effectiveness of surveillance following successful endoscopic resection of a malignant polyp. Several organizations have set forth guidelines on endoscopic surveillance following polypectomy based on patient- and polyp-specific risk factors including size, morphology, and number of polyps. 97,98 These may be extrapolated to malignant polyps, with recommendations that include marking the polyp site (ie, India ink tattoo, which should be performed by repeat endoscopy as soon as possible after pathology available, if not done at the index colonoscopy), and repeat colonoscopy in 3 to 6 months to evaluate for local recurrence. Local recurrences of malignant polyps are an indication for a segmental resection after appropriate staging evaluation. Subsequent endoscopic surveillance interval varies depending on the findings of the entire colonoscopy.

Answer 469

A Depends on experience and backup. If you’re there for obstruction, deal with the obstruction and come back another day for the oncologic problem. Loop ileo will leave long stool column with distal obstruction.

Answer 470

B <2cm means appendectomy alone is highly curative. Can’t differentiate mass vs mucocele, so would NEVER do right hemicolectomy without histology first.

Answer 471

D Deal with the emergent problem (perforation) and come back in 12-24 hours for oncologic resetion when stabilized.

Answer 472

D There are two problems: perforation and polyp. Primary repair if simple random biopsy perforation might be ok, but it doesn’t deal with a large sessile polyp which has a high likelihood of recurrence. Resection deals with both problems and can be done safely as is very early and not feculent peritonitis. >50% risk of invasive ca with polyp >3cm.

Answer 473

C FAP – 75% have CHRPE.

Answer 474

B Up to Date: Juvenile polyps — Juvenile polyps are hamartomatous lesions that consist of a lamina propria and dilated cystic glands rather than increased numbers of epithelial cells. They are usually removed because of a high likelihood of bleeding. Juvenile polyps can be diagnosed at any age, although they are relatively more common in childhood. Hamartomatous polyps — Hamartomatous polyps are polyps that are made up of tissue elements normally found at that site, but which are growing in a disorganized mass. Hamartomatous polyps have traditionally been classified as non-neoplastic but some hamartomatous polyps develop dysplasia and lead to colorectal cancer.

Answer 475

A FAP 100% Peutz Jeghrs – 50% lifetime CRC risk, 90% overall risk UC – 2% @ 10 yrs, 8% @ 20 yrs, 18% @ 30 yrs

Answer 476

A | >2cm 50% chance of invasive

Answer 477

D Dysplasia is high risk, but not absolute correlation. DALM carries 40-80% risk of concurrent invasive. LGD <10%, HGD 15-20% invasive Up to Date: The risk of CRC in UC depends upon the duration and extent of disease …The severity of inflammation may also be an important marker of risk. A case-control study found a significant correlation between the severity of inflammation as assessed by histology and the risk of colorectal neoplasia (OR 4.7)… The mortality in patients diagnosed with colorectal cancer in the setting of IBD is higher than for sporadic colorectal cancer. Cameron: risk correlated with severity

Answer 478

A Start screening 8-10 years after pancolitis, 12-15 after limited left sided disease.

Answer 479

B Expert opinion: Kvinlaug & Peti: cancer first Outdated question because of EVAR. Some sources say if aneursm <6cm, do it first, but with EVAR fix it, keep in hospital, and do colon a few days later.

Answer 480

B in answer key Would probably at least take out the appendix Seshadri: <5cm, do nothing, work up later. If >5cm, oophorectomy. No sources found. MD Anderson: unsuspected mass in young patient is usually benign; observe/workup. Oral exam: omental and peritoneal biopsy, fluid for cytology.

Answer 481

A Duodenal cancer is second most common cause of death

Answer 482

B and D in answer key Perforation and obstruction in some, but not all, reports has worse outcome. Grade, local extent, LVI, PNI, CEA, nodal involvement, CRM, R1/2 resection all consistently associated. ASCO: only considers perforation to be high risk, NOT obstruction

Answer 483

D and if women, TAH/BSO

Answer 484

A ``` Benign conditions that have been associated with an elevated CEA include [20]: ●Cigarette smoking ●Mucinous cystadenoma of the ovary or appendix ●Cholecystitis ●Liver cirrhosis ●Diverticulitis ●Inflammatory bowel disease ●Pancreatitis ●Pulmonary infections ```

Answer 485

C Bevacizumab indicated for SYNCHRONOUS lesions; given between colon and liver resections, or with neoadjuvant. Usually given in perioperative regimen between colon and liver resections. NCCN: COL-10

Answer 486

C PMP/DPAM is only validated indication for CRS/HIPEC

Answer 487

B Sessile polyps removed piecemeal: 3-6 month followup 1-2 tubular adenomas: 5 years >3 adenomas OR advanced adenoma (>1cm): 3 years >10 adenomas: <3 years

Answer 488

C Macroscopically flat or raised lesions without proper delineation to the surrounding mucosa that occur in long standing IBD are mostly diagnosed as DALM and harbor a high risk of progression to CRC (Figure (Figure1).1). Furthermore, the occurrence of DALM is frequently associated with synchronic or metachronic neoplasia. Therefore, patients with DALM are recommended to undergo prophylactic proctocolectomy with ileoanal pouch. In contrast, the term ALM describes sporadic adenomas that are similar to those observed in non-IBD patients and which are treated by standard polypectomy (Figure (Figure22).

Answer 489

A ASCRS Clinical Practice Guidelines – Sigmoid Diverticulitis The distal margin is an important determinant in minimizing the recurrence of diverticulitis and must extend to the proximal rectum to enable a colorectal anastomosis, because a colo-colonic anastomosis significantly increases the risk of recurrence.

Answer 490

A Not enough information to answer. If stem leading to surgery, procedure is subtotal colectomy with ileostomy. Currently ileostomy and vanco enemes/lavage is investigational and NOT standard of care. ASCRS Clinical Practice Guidelines – C difficile infection Subtotal colectomy with ileostomy is typically the operative procedure of choice for C difficile colitis. Grade of Recommendation: Strong recommendation based on low-quality evidence, 1C.

Answer 491

B Sabiston: Obstruction caused by a stricture at a colonic anastomosis may be treated by endoscopic balloon dilation. Segmental Colon Resection: patients with Crohn’s colitis have disease limited to a segment of colon. Segmental colon resection may therefore be an option for patients with limited colonic disease associated with stricture or obstruction. Schwartz: Chronic strictures almost never improve with medical therapy. Optimal timing for surgery should take into account the patient’s underlying medical and nutritional status. Strictures may be treated with resection or stricturoplasty. A segmental colectomy may be appropriate if the remaining colon and/or rectum appear normal. An isolated colonic stricture also may be treated by segmental colectomy. ASCRS: Patients with symptomatic strictures in any location that do not appear amenable or responsive to medical therapy should undergo operation. Approximately 7 percent of large bowel strictures in patients with Crohn’s disease are malignant,and consequently they should be surveyed for neoplastic transformation. This is usually performed with multiple biopsies and cytologic brushing. If the stricture cannot be appropriately surveyed or if neoplastic changes are identified, resection is usually warranted.

Answer 492

A NE occurs in 6% of leukemia patients, usually 12 days post-chemo. Antibiotics and bowel rest for sure, and without those options would choose G-CSF; however it is controversial and based only on expert opinion. ***ASCO considers NE to be an adverse feature and should be included in the predictors of poor clinical outcome therefore should have GCSF*** Fungal infection is also common and should be considered. Up to Date: In severely ill patients, it is reasonable to give granulocyte colony-stimulating factor (G-CSF) in an attempt to accelerate leukocyte recovery since normalization of the neutrophil count may hasten the containment and healing of bowel lesions. However, the use of G-CSF in patients with neutropenic enterocolitis remains controversial because it has not been adequately studied for this condition. In addition, some authors have raised a theoretical risk of reduced integrity of the bowel wall in the setting of an augmented inflammatory response during myeloid reconstitution Guidelines from ASCO also recommend against routine use of CSFs in this setting [febrile neutropenia] but they suggest that CSFs be "considered" for patients at high risk for infection-associated complications or who have prognostic factors that are predictive of a poor clinical outcome. These features include expected prolonged (>10 day) or profound (<100 cells/microL) neutropenia, age >65, pneumonia or other clinically documented infections, sepsis syndrome, invasive fungal infection, prior episode of febrile neutropenia, or being hospitalized at the time of the development of fever

Answer 493

B Patients with large enteroparietal, interloop, intramesenteric, or retroperitoneal abscesses may be managed by antibiotics and percutaneous drainage. If this approach is unavailable or unsuccessful, the patient should undergo surgical drainage with or without resection. Intra-abdominal abscesses in patients with Crohn’s disease typically result from a perforation that is contained by surrounding structures, and this may include segments of nondiseased bowel. Antibiotics and percutaneous drainage of a large (>5 cm) abscess usually controls the sepsis, uncommonly results in an enterocutaneous fistula, and occasionally obviates the need for future surgery. Conversely, operative drainage is much more likely to cause an enterocutaneous fistula that requires later surgery. Surgical eradication of the abscess generally requires excision of the diseased bowel responsible for the abscess and possibly the nondiseased bowel that has quarantined the sepsis. In this setting, removal of the diseased and nondiseased bowel risks immediate or future short bowel syndrome.

Answer 494

C Likely gout precipitated by systemic illness, but there are case reports of diverticulitis-associated septic arthritis, but gout is more likely. Without previous gout diagnosis, arthrocentesis, microscopy for crystals, and cell count is warranted.

Answer 495

C Up to Date: CT is best, diagnosis usually made through secondary features.

Answer 496

B Stool culture most sensitive, but doesn’t differentiate infection vs carriage. Immunoassays for toxin A & B are commmon but poorly sensitive. Cell cytoxicity assays have variable sensitivity. Immunoassay for GDH followed by stool culture has high SN, SP, and PPV. The method of detection is clinically important, because sensitivities vary between culture and antibody testing. Cell cytotoxicity assays, which test for cytopath caused by toxins A and B, have reported sensitivities between 60% and 100%. In contrast, stool culture is highly sensitive, but does not differentiate between active infection and the presence of Clostridium spp. bacteria; several nontoxigenic, nonpathologic strains may grow in culture. Therefore, culture is commonly used in conjunction with toxin detection. Antigen recognition using enzyme immunoassay testing for toxins A and B is inexpensive and rapid, leading to increased use. However, its low sensitivity (39%–76%) despite adequate specificity has made this test less suitable when used alone. Glutamate dehydrogenase (GDH) is another enzyme that has been shown to be highly sensitive but nonspecific for CDI. Two-step testing, involving enzyme immunoassay to detect GDH as an initial screening step, followed by cell cytotoxicity or toxigenic culture for GDH-positive samples, is 1 method used to overcome the limitations of other methods. Reported sensitivities, specificities, negative predictive value, and positive predictive values are 91.57%, 98.07%, 99.03%, and 84.44%.

Answer 497

A Repeat question with variation; previous years was post-appendectomy fistula. This is low output (<500cc/24hrs), distal fistula without sepsis. 38% will close spontaneously; those that will close do so within 3 months. 4 weeks too soon for surgery. Goal is to get albumin to 30. Up to Date: Colocutaneous fistulas — Conservative and supportive management is the initial approach for patients with a colocutaneous fistula, since approximately one-half will close spontaneously at a mean of 30 days (range 10 to 180 days) [72]. If the fistula persists longer than six weeks or is a high output fistula, it is less likely to close spontaneously. Definitive operative intervention should be delayed for approximately three to six months to allow for resolution of sepsis and/or to restore nutritional status.

Answer 498

B Rule out abscess that could be perc drained before operating.

Answer 499

A vs B I personally would do B first Ischemic colitis; assess for viability. Some people would do CT first. Ischemic colitis has been reported to occur in approximately 2% to 13% of cases after open aneurysm repair. The ischemia may result from inadequate resuscitation, disruption of collaterals, and/or failure to revascularize a hemodynamically significant inferior mesenteric artery. Patients usually present with bloody diarrhea in the early postoperative period. The diagnosis may be confirmed by endoscopy. Although sigmoidoscopy is used most frequently, a complete colonoscopy is likely optimal due to the potential involvement of the other colon segments. Treatment depends on the endoscopic findings and clinical setting. The endoscopic findings range from mucosal ischemia to transmural necrosis. Unfortunately, it is often difficult to differentiate diffuse mucosal ischemia from transmural necrosis. Patients with mucosal ischemia alone should be treated with bowel rest, broadspectrum antibiotics, total parenteral nutrition, and serial endoscopic examinations. Many of these lesions resolve spontaneously without long-term sequelae, although colonic strictures may develop in a subset of patients. Patients with transmural colonic necrosis should undergo laparotomy with resection of the involved segment, a proximal diverting colostomy, and a distal Hartmann pouch. After laparotomy, they should be maintained on broad-spectrum antibiotics and parenteral nutrition.

Answer 500

B Depends on age. If > 4-5 years, juvenile polyp is most likely. Under 2 Meckels most common, 2-5 both are possible. The likely causes of lower gastrointestinal bleeding (LGIB) vary depending upon age. In the United States, the most common causes of rectal bleeding in infants are anal fissure or cow’s milk or soy protein-induced colitis. In children 12 months and older, the most common causes of rectal bleeding are infectious gastroenteritis and anal fissures. In each age group there are other disorders that are less common but important to identify because they may be life-threatening and/or require specific treatment. The spectrum of causes is different in other parts of the world. In a report from India, for example, 24 percent of 85 children bled from amoebic ulcers. Infants and toddlers — The most common causes of bleeding in infants and toddlers (one month to two years) include: • Anal fissures (especially around the introduction of solid food or cow’s milk) • Milk or soy protein-induced colitis (allergic colitis) • Intussusception • Infectious colitis • Meckel's diverticulum • Lymphonodular hyperplasia • Gastrointestinal duplication cyst • Coagulopathy

Answer 501

C Schwartz Obstruction that occurs in the early postoperative period is usually partial and only rarely is associated with strangulation. Therefore, a period of extended nonoperative therapy (2–3 weeks) consisting of bowel rest, hydration, and total parental nutrition (TPN) administration is usually warranted. However, if complete obstruction is demonstrated or if signs suggestive of peritonitis are detected, expeditious reoperation should be undertaken without delay.

Answer 502

A Unwell so requires drainage. Laparoscopic/open surgical drainage is possible, but will likely require bowel resection of the perforation and adherent bowel. No anastomosis in this setting.

Answer 503

B Evaluation is needed to rule out neoplasm, so CT vs scope. CT cannot rule out small obstructing neoplasm.

Answer 504

A Crohn’s disease of the appendix, moderate output after 6 weeks predicts wont close. Might be reasonable to remove the drain first to lengthen the tract, but this will need surgery.

Answer 505

A Can observe if cecum <14cm. Medical management is 1st line, colonoscopic decompression 2nd. In this case, patient is on BB so neostigmine contraindicated.

Answer 506

B Largest series is from Mayo Clinic, 1955-2005; they advocate resection if any of the following are met: age <50, male, >2cm length, palpable abnormality. These features are associated with development of symptoms. Worse morbidity with incidental Meckel’s resection, especially if elderly, which this patient probably is. Resect if symptoms, if palpable abnormality, and in children. Can make an argument to resect in <50 years if long (>2cm) or have a very narrow base. This scenario has an incidental, elderly, broad-based diverticulum so clearly no resection- deal with the reason you’re there. If operating for bleeding MD, do a SB resection not diverticulectomy to get the ulcerated portion. Cameron: From a meta-analysis of 244 studies, Zani and colleagues reported increased morbidity associated with incidental resection over no treatment and determined that more than 700 patients with incidental Meckel's diverticulum required resection to avoid one Meckel's-related death. Thus, general practice is to resect incidentally found Meckel's diverticulum in children but not in adults.

Answer 507

B Up to Date: In symptomatic patients with diversion colitis, restoring intestinal continuity by surgical reanastomosis is first-line treatment…SCFA enemas are used as initial therapy in patients with diversion colitis who are unable or unwilling to undergo surgery and in patients with known distal IBD in whom the diagnosis of diversion colitis is unclear. In patients with underlying IBD, we use SCFA enemas in combination with topical antiinflammatory drugs.

Answer 508

A Complicated diverticulitis should be resected electively (ASCRS specificies resect if abscess >5cm or pelvic abscess). Of note, free air alone does NOT constitute complicated disease.

Answer 509

A LGD: invasive in up to 20%; HGD: invasive in 20-40%; DALM: 40-80%

Answer 510

C AA in pregnancy needs to be imaged to rule out other causes of pain. U/S is 1st line, MRI next if available (SN/SP/NPV approach 100%), limited CT if MRI not available (cGy 3 vs usual 30). Management is always surgical, risk is lesser than observation. Fetal mortality up to 35% if perforates, therefore negative laparotomy rate of 25-30% is acceptable. Lap appy reasonable in early pregnancy, depending on height of uterus. Use left lateral tilt, pneumoperitoneum pressures of 12mmHg, direct visualization port placement. Open surgery is completely accepted. Leukocytosis up to 16 is normal in pregnancy, and can be up to 29 in labour.

Answer 511

A Signs of necrosis, so don’t want to devolve. Signs of impending perforation. Remember, if you detort, do colectomy on same admission.

Answer 512

B vs D Don’t want to do a subtotal for a stable, non-bleeding patient given high risk of rebleed. HOWEVER, if failed to localize on angio 2 times, algorithms say subtotal colectomy, so subtotal is very reasonable.

Answer 513

A Uncomplicated, so stoma care should be adequate. If complicated, local revision preferred. Uncomplicated prolapse can be managed conservatively with cool compresses and/or application of an osmotic agent (eg, table sugar or honey) to reduce edema, followed by manual reduction of the prolapse and application of a binder with a prolapse over-belt to keep the bowel recued into the abdomen, or by pouching modifications to accommodate the prolapsed bowel when reduction cannot be established or maintained. Manual reduction should be initiated at the very tip of the prolapse (beehive) or lumen, and then gentle, slow invagination should proceed. In this way, the prolapsed bowel will intussuscept back into the abdomen. Complicated prolapse or prolapse producing ischemic changes or severe mucosal irritation and bleeding usually requires surgical intervention. Local revision of the prolapse is accomplished by performing a full-thickness resection of the prolapsed intestinal segment with construction of the stoma at the original site.

Answer 514

A Incidence of PSH is up to 50%, highest for end colostomy > end ileo > loop colo > loop ileo. Multiple studies demonstrate safety of mesh-based repairs and much lower recurrence rates. Any mesh is superior to primary repair (recurrence of 5-17% vs 70%), debate whether keyhole has lowest recurrence risk. Overall risk of mesh infection is 6-20%. Laparoscopic repair has no difference in morbidity and mortality, but slightly high recurrence. Resiting has the same incidence of hernia formation! The use of a biologic substitute obviates the placement of prosthetic mesh material near the stoma, which is a contaminated site. Although data are limited regarding the use of biologic substitutes for repair of parastomal hernia, these should be considered in patients who are at high risk for prosthetic mesh complications, such as those with inflammatory bowel disease or risk factors for wound infection. The expense of biologic substitutes, which can cost thousands of dollars per piece, probably cannot be justified for others.

Answer 515

C UTD For patients who present with localized peritonitis and low-grade sepsis, a diagnostic imaging work-up is initiated. We perform a CT scan with oral, intravenous, and rectal contrast. Alternatively, a water-soluble contrast enema may be performed, if available in your institution. If a leak is present, the majority will be localized. •If a free intraperitoneal leak is demonstrated, the patient should be taken to the operating room for surgical management. •If the patient is stable with small, contained abscesses (<3 cm), we recommend conservative management with broad-spectrum antibiotics and bowel rest. •For larger abscesses (>3 cm), multiloculated collections, or multiple collections, an attempt at percutaneous drainage should be made. In those cases where image-guided drainage is not technically feasible or where the patient’s clinical condition deteriorates despite drainage, surgical intervention in the form of an exploratory laparotomy should be undertaken as described in the following paragraph. ●Patients who present with generalized peritonitis or high-grade sepsis with hypotension should be resuscitated and brought to the operating room for an exploratory laparotomy on an emergent basis. Surgical management is dependent upon the intraoperative findings. •If an inoperable phlegmon is encountered, the safest approach is to place para-anastomotic drains and perform proximal temporary fecal diversion with either a loop ileostomy or colostomy. For patients who have a major anastomotic defect (generally defined as >1 cm or greater than one-third the circumference of the anastomosis) [49], the options include resection of the anastomosis with creation of an end stoma with/without mucus fistula, resection of the anastomosis with re-anastomosis and proximal diversion, or, rarely, exteriorization of both ends of the stoma. In selected patients in whom the defect is minor and the tissue quality is adequate, one may consider primary repair of the anastomosis with drain placement and proximal diversion.

Answer 516

B Common cause of GIB in children: anal fissure, milk colitis, Meckels, polyps, etc. Right age for Meckels and doesn’t sound like UGIB. DDx for UGIB in kids is esophagitis, peptic ulcers, foreign body trauma, gastritis, M-W. BRBPR more consistent with polyp, altered blood more likely MD.

Answer 517

C Up to Date: ETIOLOGY OF MESENTERIC ARTERIAL OCCLUSION — The two major causes of acute mesenteric arterial occlusion are mesenteric arterial embolism and mesenteric arterial thrombosis. In an autopsy study, the ratio of superior mesenteric embolus to thrombus ratio was 1.4:1. Arterial embolism – Embolism to the mesenteric arteries, which may partially or completely occlude the arterial lumen, is most frequently due to dislodged thrombus from the left atrium, left ventricle, cardiac valves, or proximal aorta. Systemic embolization occurs in 22 to 50 percent of cases of infected endocarditis with embolization to the viscera second only to cerebral embolism [4]. A history of prior embolization is common. The large diameter and narrow take-off angle of the superior mesenteric artery (SMA) make it anatomically most susceptible to embolism. The inferior mesenteric artery is rarely affected due to its small caliber [5]. The embolus usually lodges 3 to 10 cm distal to the origin of the SMA, in a tapered segment distal to the take off of the middle colic artery, but approximately 15 percent of emboli lodge at the origin of the SMA [6]. The middle segment of the jejunum, which is most distant from the collateral circulation of the celiac and inferior mesenteric arteries, is most often involved in the ischemic process, whereas the proximal jejunum is usually spared. Arterial thrombosis – Arterial thrombosis occurs at areas of severe narrowing most typically due to atherosclerosis. Acute thrombosis of the mesenteric circulation often occurs as a superimposed phenomenon in patients with a history of chronic mesenteric ischemia from progressive stenosis due to atherosclerotic plaque, also referred to as acute-on-chronic ischemia. Thrombosis of the SMA or celiac axis usually occurs at the origin of the vessel, and involvement of at least two major mesenteric arteries is generally needed for the patient to have significant symptoms because of the development of the collateral circulation over time. A palliative approach may be the best option for poor risk surgical candidates with extensive transmural infarction (eg, small bowel up to the mid-transverse colon). Extensive bowel resection would be inappropriate for these patients and may also be inappropriate for a subset of patients who might otherwise be expected to tolerate the procedure, but for whom lifelong parenteral nutrition would be unacceptable. The traditional treatment for mesenteric embolism is open surgical embolectomy, which, in addition to expeditiously clearing the thrombus, allows direct assessment of bowel viability. Open surgical treatment of mesenteric artery thrombosis is treated principally with mesenteric bypass. Thrombectomy alone is unlikely to offer a durable solution, due to the presence of thrombogenic atherosclerotic plaques

Answer 518

C Idiopathic small-bowel intussusception in an adult. CMAJ, 2010-02-23, Volume 182, Issue 3, Pages E148-E148 In adults, intussusception is exceedingly rare, representing less than 5% of all intestinal obstructions. In contrast to the pediatric population, about 90% of intussusceptions in adults are associated with a pathologic lesion, or lead point, in the bowel wall. Recent studies show that 30% of small-bowel intussusceptions are caused by malignancy. The remainder of instances are caused by benign lesions (60%) or are idiopathic (10%). Most colonic intussusceptions, however, are caused by malignancy (60%). Almost 90% of the cases of intussusception in adults are secondary to a pathologic condition that serves as a lead point, such as carcinomas, polyps, Meckel’s diverticulum, colonic diverticulum, strictures or benign neoplasms, which are usually discovered intraoperatively[5–7]. Due to a significant risk of associated malignancy, which approximates 65%[8,9], radiologic decompression is not addressed preoperatively in adults. Therefore, 70 to 90% of adult cases of intussusception require definite treatment, of which surgical resection is, most often, the treatment of choice[10].

Answer 519

A Generally would resect MD in kids, however in the setting of perforated or gangenous appendicitis this should not be done; still ok if simple appendicitis – see small bowel questions for source.

Answer 520

D Below internal iliacs (or lower 1/3) reimplantation is best. First shot is best, so should be done by urologist, so drain and refer. Cameron: Low ureteric injuries are the easiest to manage with reimplantation. Most midureteral transections can be repaired by primary ureteroureterostomy. The repair should be tension-free, watertight, and spatulated over a double-J stent. All ureteral injuries where débridement and reanastomosis are required follow the same reconstructive principles: 1. Ureteral dissection that preserves the supporting adventitia and does not skin the ureter, which can lead to vascular compromise and stricture, is required. 2. Appropriate ureteral débridement to a bleeding edge must be performed. High-velocity projectiles can result in blast injury and ischemia, which can produce occult injury up to 2   cm away from the transection. 3. The repair should be a tension-free, watertight, spatulated, mucosa-to-mucosa anastomosis. 4. A ureteral stent should be employed. 5. Wrapping the ureter with omentum or local tissue flaps helps support the ureter and isolate it from adjacent organs. 6. To prevent urinoma, a drain adjacent to the repair, but not overlaying it, should be left.

Answer 521

A PROBABLY but not necessarily primary ileal CD. If just adherent to sigmoid, can mobilize, resect ileum, and repair sigmoid. Repair incidental bystander. ASCRS: Fistulas originating in diseased bowel and secondarily involving other intra-abdominal organs or the skin are not usually associated with localized or systemic sepsis. Regardless of whether an abscess is present, persistent sepsis usually warrants excision of the diseased bowel. Management of the target or innocent bystander organ is based on whether it is diseased bowel, noninflamed bowel, or another internal organ. Diseased bowel is generally resected, noninflamed bowel can be primarily closed, and other internal organs (e.g., bladder, vagina) can be primarily closed or left to heal by secondary intention.

Answer 522

B Gold standard is Hartmann’s, however resection, anastomosis, and diversion is reasonable in non-feculent peritonitis. The stem doesn’t indicate diverting ileostomy, so wouldn’t choose resection and anastomosis without diversion.

Answer 523

B Genitofemoral travels on psoas, so very possible. Lateral cutaneous nerve also possible. II and IH less likely as are intramuscular so shouldn’t be near them.

Answer 524

E Heyde's syndrome is a syndrome of gastrointestinal bleeding from angiodysplasia in the presence of aortic stenosis.

Answer 525

A Amoebic colitis may have small 3-5mm ulcers. Usually limited colitis but can progress to toxic megacolon and perforation. Diagnosis is usually by stool microscopy for O&P. Treatment with with 2 agents – Flagyl and another drug to eradicate luminal cysts.

Answer 526

All different in UC vs Crohn's UC - Mucosal inflamm characteristic - Width of submuscosa N or often reduced - Intense vascularity, little edema - Focal lymphoid hyperplasia restricted to submucosa, mucosa, and superficial submucosa - Crypt abscesses very common - Epitheliod granuolmas absent from bowel and LNs - Lack of goblet cells and thin mucin layer - Fissuring absent - Precancerous epithelial change occurs - Anal lesions--non specific inflamm Crohn's - Patchy transmural inflamm - Submucosal width N or incr - Vascularity seldom prominent, edema marked - Focal lymphoid hyperplasia in mucosa, serosal and pericolic in mucosa, serosal and pericolic tissues - Crypt abscesses fewer in number - Epitheliod cell granulomas in 60-70% of cases in bowel and LNS - Normal goblet cell retention and mucin layer thicker than normal - Fissuring very common - Precancerous change uncommon - Anal epitheliod cell granulomas often present

Answer 527

E UC: crypt abscesses, crypt atrophy, mucosal inflammation, goblet cell depletion,

Answer 528

Answer key says C. But maybe D But Crohn's has N goblet cells. UC has decr goblet cells.

Answer 529

C Systemic amyloidis is associated with IBD; only rare case reports of neuritis. Up to Date: Extraintestinal manifestations — Although ulcerative colitis primarily involves the bowel, it is associated with manifestations in other organ systems. Although less than 10 percent of patients with inflammatory bowel disease (IBD) have an extraintestinal manifestation (EIM) at initial presentation, 25 percent of patients have an EIM in their lifetime . ●Musculoskeletal – Arthritis is the most frequent EIM of IBD. IBD is associated with both a nondestructive peripheral arthritis, which primarily involves large joints, and ankylosing spondylitis. Other musculoskeletal manifestations of IBD include osteoporosis, osteopenia, and osteonecrosis. ●Eye – The most frequent ocular manifestations of IBD include uveitis and. ). Scleritis, iritis, and conjunctivitis have also been associated with IBD. Affected patients may be asymptomatic or complain of burning, itching, or redness of the eyes. ●Skin – The most frequent skin lesions associated with IBD include erythema nodosum and pyoderma ●Hepatobiliary – Primary sclerosing cholangitis, fatty liver, and autoimmune liver disease have been associated with IBD [pericholangitis] ●Hematopoietic/coagulation – Patients with IBD are at an increased risk for both venous and arterial.

Answer 530

A or C in answer key. My guess is A

Answer 531

Answer key saysD but all do.

Answer 532

A and C in answer key but I think A is a better answer

Answer 533

A Sessile 5 cm polyp has a 50% chance of malignancy

Answer 534

B One of the more controversial points in the management of diverticulitis involves the appropriate selection of patients for elective sigmoid colectomy after recovery from an uncomplicated episode. Based on large retrospective series, it is estimated that, after an initial attack, approximately one-third of patients will have a recurrent episode, and that one-third of those patients are expected to have yet another recurrence.39,40 The accuracy of these recurrence rates has been questioned because the source literature predates the routine use of cross-sectional imaging. More recent studies examining the natural biology of uncomplicated diverticulitis treated nonoperatively report lower recurrence rates ranging from 13% to 23% and low rates of subsequent complicated disease or need. After recovering from an initial episode of diverticulitis, the estimated risk of needing emergency surgery with stoma formation is 1 in 2000 patient-years of follow-up.39 According to this, 18 patients would need to undergo elective colectomy to prevent 1 emergency surgery for recurrent diverticulitis.42 The practice of recommending elective colectomy to prevent a future recurrence requiring stoma formation is not supported by this literature and should be discouraged. Despite previous emphasis on the number of attacks dictating the need for surgery, the literature demonstrates that patients with more than 2 episodes are not at an increased risk for morbidity and mortality in comparison with patients who have had fewer episodes, signifying that diverticulitis is not a progressive disease. Rather, most patients who present with complicated diverticulitis do so at the time of their first attack.

Answer 535

C Level I evidence for primary repair in ALL nondestructive (Grade I-II) colonic injuries. Level II evidence supports resection and primary anastomosis for ALL colon injuries, regardless of risk factors. However, surgical dogma, based on 1998 EAST Guidelines, suggests diversion if delay >6hrs, >6 units transfused, or fecal peritonitis, shock, severe underlying disease. Current best evidence says that there are less complications with primary anastomosis than with colostomy, regardless of risk factors. ASCRS Manual: “Colon injuries requiring resections should be managed by primary repair, irrespective of risk factors.”

Answer 536

D in answer key I would probably at least take the appendix. If concerned about malignancy, I might leave it alone and post con op consult gyne to work it up.

Answer 537

C If DALM 50% 12% syncrhonous cancer

Answer 538

Answer key says B but sounds like the patient is pretty sick so maybe C?

Answer 539

B Cytomegalovirus infection can complicate both ulcerative colitis and Crohn's disease. The virus belongs to the herpes virus family and 40-100%1 of the adult population have been infected. Most infections are subclinical and lead to lifelong latency. However, in immunocompromised individuals such as transplant recipients and AIDS patients, the virus can cause severe disease. A connection has been suspected between cytomegalovirus inclusion disease and ulcerative colitis since 1961.2 The prevalence of cytomegalovirus complicated colitis in patients with inflammatory bowel disease has been estimated at 0.53-4%,3-4 but in patients presenting with severe steroid refractive Crohn's disease it is thought to be much higher at 11-36%.5 Clinical pointers to viral complications include persistent severe hypokalaemia, high spiking pyrexia, lymphadenopathy and bone marrow suppression3 but such features are seen also in patients with uncomplicated severe steroid-resistant Crohn's colitis. The recommended means of diagnosis is histological examination of biopsies from the affected mucosa and ulcer beds.3,5-6 Serological tests and virus isolation from blood or faeces do not prove colonic infection. With earlier diagnosis the present patient might have been spared surgery. When cytomegalovirus infection is found to be complicating Crohn's colitis, steroid treatment should be reduced, other immunomodulatory treatments stopped, and ganciclovir 10-15 mg/kg daily in divided doses given for 2-3 weeks.3,6 Such treatment has reduced emergency colectomy rates from 80% to 33% and case fatality from 33% to 5% in patients with severe steroid-refractory inflammatory bowel disease complicated by cytomegalovirus infection. However, about one-fifth of patients so treated need colectomy within three months because the underlying bowel disease has become reactivated or the viral infection has persisted.6

Answer 540

A Cochrane Review: Surgery for right-sided bowel cancer or Crohn's disease commonly involve removing a segment of bowel and re-joining the small and large bowel together. The join, or anastomosis, can be made by stapling or sewing. This systematic review found seven randomised controlled trials with a total of 1125 participants (441 stapled, 684 handsewn) comparing these two methods. The leak rate from the bowel join for stapled anastomosis was 2.5%, significantly lower than handsewn (6%). For the sub-group of 825 cancer patients in four studies, stapled join again has fewer leaks compared with handsewn, being 1.3% and 6.7% respectively. For the sub-group of 264 non-cancer patients in three studies, there were no differences for the reported outcomes. This sub-group included patients with Crohn's disease. Overall, there was no significant difference in the other outcomes of stricture, bleeding from the join, time to perform the join, re-operation, mortality, intra-abdominal abscess, wound infection and length of stay, although these were not consistently reported. The reason why a handsewn bowel join is more likely to leak is unclear. Possible explanations include less handling of the bowel, decreased spillage of bowel content during surgery, and uniform closure of all the staples using a stapler. This review did not compare different sewing materials or methods. The trials included in this review were performed from the early 1980's to 2009 involving six countries. The studies in Crohn's disease were more recent but the combined number of patients was too small to summarise outcomes. More randomised controlled trials comparing the two surgical techniques in Crohn's disease are needed.

Answer 541

D vs B in answer key Personally would go with D

Answer 542

C Colonoscopy not sigmoidoscopy

Answer 543

C HCC is 5th most common cancer worldwide, 5.6% of all malignancies. 3rd most common cause of cancer related death. Wide geographic variation in incidence, predominating in Asia and Africa. Worldwide, remains a disease of men. Chronic infection with either hep B of C accouts for up to 70% of HCC cases. Presence of cirrhosis increases the risk of developing HCC. With it, annual incidence of HCC can approach 6%. Risk of HCC is also high in the setting of cirrhosis from genetic hemochromatosis and PBC. Cirrhosis secondary to alcohol and alpha 1 antitrypsin deficiency also increases the risk of HCC NAFLD is now emerging as a significant RF for the development of HCC, and given, its prevalence, it has the potential to surpass Hep B and C as the leading cause of HCC. Yearly cumulative incidence of HCC in NASH assoc cirrhosis was more than half that of Hep C. NASH carried a risk for the development of HCC that rivaled that of Hep C (20x incr). Such a risk is similar to hemochromatosis (20x incr), and surpasses the calculated risks for alcohol (5x risk) as well as for PBC, alpha 1 anti-trypsin and diabetes (2-3x incr) B/C early detection of HCC is criticial for successful therapy, surveillance of at trisk populations is recommended. Such surveillance is performed using hepatic U/S and AFP monitoring q6months. Combined, the 2 modalities have a sensitivity up to 85% and a specificity that can approach 90%

Answer 544

E 0.3% bile duct injury. Three steps to establising the critical view of safety. First, the traingle o Calot must be cleared of fat and fibrous tissue. Does not require that the CBD be exposed. Seoncd requirement is that the lowest part of the gb be separated from the cystic plate Cystic plate is described as the flat fibrous surface to which the non peritonealized side of the gb is attached, commonly called the liver bed. Third requirement is that 2 structures, the cystic duct and cystic artery, be seen entering the gb.

Answer 545

B ~15% of pts present with typical biliary tract symptoms and no detectable cholelithiasis, yet they undergo cholecystectomy RUQ pain in these pts is characteristically 30-60 mins post prandial and lasts >1 hr. RUQ tenderness is not common and is mild if present. Ddx for acalculous biliary pain is braod and incl infectious causes (e.g. hep A, B, EBV, CMV, salmonella, typhoid), inflammatory (IBD, PSC, vasculitis, SLE, polyarteritis nodosa), pancreatitis, gastritis, ulcer disease, and sphincter of oddi dysfunction. Full diagnostic evaluation should be undertaken before proceeding to chole. Liver tests, U/S and endoscopy are necessary to r/o a luminal process. CT scans are unhelpful. Medical mgmt has at least a 50% assoc with pain relief. HIDA scan with an abN CCK gallbladder EF is the single most predictive test in predicting a benefit from chole in pts with postprandial RUQ pain and no evidence of gallstones. GB EF of <10% (Normal >38%) is assoc with a >70% likelihood of pain relief after chole.

Answer 546

D Solitary hepatic adenomas (HAs) are rare benign liver tumors most freq, through no exclusively, seen in premenopausal women with a hyperstrogen state such as OCP use and obesity. When hepatic adenomas are dx in men, esp those on anabolic steroids, the risk of malignancy is higher. HAs are monoclonal proliferations of liver cells akin to adenomas in other organs.. Commonly detected as incidental findings on axial imaging. CT or MRI features can be diagnostic, but often the ddx incl FNH and HCC. Bx is indicated when malignancy is a concern Risk of hemorrhage and malignant degeneration in tumors > 5 cm. Asymp pts with modifiable RF such as OCPs may undergo a withdrawal trial under close interval observation. Lack of regression off OCPs is not by itself an indication for resection and does not correlate with malignant potential Bleeding from ruptured hepatic adenomas can be life threatening and is best managed in the acute setting by angioembolization. Bleeding rarely occurs in tumors <5 cm. Pts who have lesions >5 cm especially with radiographic evidence of hemorrhage are candidates for resection Risk of malignant degeneration also appears to increase with size. Inactivation of hepatocyte nuclear factor 1a (HNF-1-alpha) is a favorable feature. Beta catenin activation, seen as muclear localizing on immunohistochem, is more commonly assoc with an incr potential for malignant degeneration

Answer 547

C R0 resections (histologically neg margins) are essential. Tumor ablation is a tool to be used not as a replacement for resection but to be used sparingly as an adjunct for small tumors not amenable to resection. B/C systemic therapies have higher and more reliable response rates, a neoadj approach is recommended for pts with surgically boerderline liver mets. Response to therapy stratifies the likelihood of gaining a benefit from resection--progression/nil, stable disease/guarded, good response/clear benefit Limitations on liver functional liver volume, where the FLR is <25% of the preresection total. can be enhanced in some cases by ipsilateral portal vein embolization. In this approach, the liver segments to be resected undergo PVE several weeks before resection. During this time, the FLR is stimulated to "pregrow", with an expected mitigation of risk of post op liver failure

Answer 548

C Incidentally identified panc masses are an increasingly common clinical challenge.In otherwise fit pts, solid tumors, merit tissue dx to direct therapeutic recommendations. Tumosr is not cystic and ddx incl panc endocrine tumor or adenoca. A tissue dx is essential to establish the dx and direct therapy. EUS is the most direct route to establish the dx and stage a malignancy. Percutaneous bx should be avoided b/c it does not offer the detailed staging, suh as LN biopsy, as does EUS. In the absence of symp, the lesion is defined as nonfunctioning. Obtaining a broad panel of serum hormones before establishing the dx, such as CIP is of no immediate use. Ki67 is a histopathologic proliferation marker assay done on tissue obtained at bx or resection. Ki67 levels >2% indicated a higher risk of malignant behavior in panc neuroendocrine tumors. Delayed CT might be appropriate after a dx is established. For pts with well diff panc NET <2 cm, surgical resection does not confer a survival advantage so a pt focused risk assessment should be undertaken. PET scan has not been validated for panc endocrine tumors, and is not recommended. Somatostatin scintigraphy is used in staging these patients buts its sensitivity may be limited in low volume disease

Answer 549

C 2.6% incidence of incidental panc cysts on routine CT scans. Pt is asymp with a cystic lesion <2 cm. Ddx incl mucinous, serous, or endocrine cystic neoplasms and postinflam, infectious, and congenital etiologies. Natural hx of incidental cystic lesions of this size is broadly benign. MRI is chose b.c of its superior resolution to recognize septae, nodules, and duct communication compared with CT Any sinister features (i.e. nodular components to the cyst wall, panc duct diln, regional LNs) would direct further investigation iwith EUS. EUS and FNA would be indicated to establish a tissue dx >95%. Only after the dx is established would additional testing, such as CA 19-9 in the setting of adenoca be required.

Answer 550

E Pts with cirrhosis are at an incr risk of developing HCC. Ability to secure a dx depends on the size of the lesion and its imaging characteristics. Bx is reserved for pts with atypical imaging. Cirrhosis is a dx made by histopathology. Staging of cirrhosis is a function of clinical and lab findings but not histopathology. PET has no utility for the dx or staging. AFP is a useful test but its sensitivity is <80% and therefore it is not a diagnostic test

Answer 551

E Eralier return of bowel function and fewer pulmonary complications without NG tubes, Trend for shorter LOS in the non NG tube group.

Answer 552

C Iatrogenic biliary injuries occur in 0.3-0.8% of lap choles. Majority that occur during lap chole are not recognized at the initial operation. Patients present with abdo pain, intolerance of diet, and low grade fever. Pt has a stricture of CHD with elevated bilis and cholangitis. Imaging shows no retained stone. Initial imaging studies, such as CT or US may reveal dilated hepatic ducts or a fluid collection. IR drainage of these collections can be very helpful. A. PTC may be valuable in delineating the anatomy and in providing prox biliary drainage. The most favorbale long term results are with surgical repair. Use of stents or balloon dilitation of the duct do not lend to satisfactory outcomes. Repair is best performed by an experienced biliary surgeon and should be guided by the type of injury. Lateral duct injuries can be repaired over a T tube. Injuries that are more extensive may require biliary enteric anastomosis. In this patient, there is a stricture of the CHD with an assoc clip. This type of injury requires surgical exploration and appropriate repair. There is no assoc biloma for CT guidede drainage. An additional R sided PTC is no indicated, b/c the PTC demonstrates the anatomy adequately and provides good drainage

Answer 553

C Hernias repaired primarily have recurrence rates that can range from as low as 11% to as high as 54%. These data are derived primarily from cohort studies, and little level 1 evidence is available. One prospective randomized study assigned hernia pts to suture repair or mesh repair. Patients underwent repair of a primary hernia or a first recurrence of hernia at the site of a vertical midline incision of the abdomen of <6 cm in length or width. The patients were followed up by physical exam at 1, 6, 12, 18, 24 and 36 months. Among the 154 pts with primary hernias and the 27 pts with first time recurrent hernias who were eligible for the study, 56 had recurrences during the follow up period. The 3 year cumulative rates of recurrence among pts with a primary hernia who had suture repair and those who had mesh repair were 43% and 24% respectively.

Answer 554

C In RCT of open mesh or lap mesh repair, recurrence was more common after lap repair than open repair. Recurrence rates after repair of recurrent hernia were similar in the 2 groups. Wound infection was 1.4& in the open group and 1.0 % in the lap group. Complications occurred in 27% and 15.1% of acute and elective repair pts. However only 1.4% of male pts required orchiectomy. Although nonop observation can be considered in mildly symp and asymp pts, according to the inguinal hernia guidelines of the European Hernia Society, inguinal hernia pts without contraindications should usualy be tx operatively b/c of the incr complciation and mortality rates with emergent surgery. Inability to reduce a hernia with a nonop approach has been reported to be 0.4% per year, with a mean annual recurrence rate after surgery to range from 0.2-4%

Answer 555

B Risk of bile duct injury with lap chole is 0.3-0.8%. Intraop cholangiography is assoc with lower risk of bile duct injury;however, it does incur additional cost, lengthens the OR time and is not routinely performed on all cases. Error of viual perception is the most common reason for bile duct injury. The critical view of safety approach should be used during all lap chole cases, b/c it is accepted as 1 method to decr the risk of bile duct injury. Dissect the triangle of Calot to allow 1/3 of the gallbladder to be dissected free from liver bed, clear the triangle of calot to allow visualization segment V of liver visible through the window and ensure that the cystic artery and duct are the only structures between the gb and hepatoduodenal ligament. RF for bile duct injury include obesity, advanced age, male, severe inflam or infection, aberrant anatomy, hemorrhage, and surgeon experience. Only 10-30% of bile duct injuries are recognized at the itme of the OR. Most injuries are recognized postop, often after the pts is d/c from hospital. Earlier detectin of bile duct injuries is assoc with improved outcome. Delayed repair is recommended in cases with sepsis, severe local inflam, or the presence of a bile collection (biloma) to allow time for the pt to be medically optimized and for inflamm to decr. IN cases with fluid collection in the gb fossa, a HIDA scan can determine whether the collection connects with the biliary tree and help dx a bile leak.

Answer 556

D Groove pancreatitis is a form of chronic segmental pancreatitis that appears as scarring in the groove between the panc head, duodenal wall, and CBD. Freq this may appear as a poorly enhancing mass int eh rgion of the head of the panc with adjacent inflam changes to the duodenal wall on CT imaging. Characteristic that distinguish this entitiy from panc cancer include smooth biliary duct narrowing and N enhancement of the panc head. Perc drain of the pancr abscess in critically ill pts, those with recurrent abscesses and those with portal HTN has been proposed as an effective temporizing measure. If improvement is not seen after the initial drainage, the CT should be repeated and a second drainage procedure or OR may be planned at that time. Panc necrosis is assoc with a higher mortality rate (25%) and is assoc with further complications in >80% of pts. It was formerly recommended that all cases of panc necrosis be surgically debrided. Currently, conservative mgmt is recommended using perc drain before necrosectomy. Some advocate sx intervention only for cases of >50% of panc necrosis bc of risk of infection and mortality. Panc pseudocysts may occur after pancreatitis. Spont resolution of these cysts is common. Venous thrombosis occurs in approx 13-24% of pts and presents as splenomegaly and gastric varices. Variceal hemorrhage occurs rarely and can be effectively tx with splenectomy.

Answer 557

A Type I variant is often considered normal anatomy and is most commonly found. Here, the common hepatic artery gives off the GDA to become the proper hepatic artery, which branches to the R, middle and L hepatic arteries within the porta hepatis During the course of Whipple, the GFA must be ligated and divided, but flow to the liver via the hepatic arteries must be preserved. In the setting of proximal stenosis or occlusion of the origin of the common hepatic artery, the SMA provides flow to the liver via the pancreaticoduodenal arcade and retrograde flow through the pancreatic arcade often results in enlarged or even aneurysmal vessels within the pancreatic head. Ligation of the GDA isn this setting results in loss of pulsatile flow in the prox common hepatic artery. 2 most common causes of stenosis of the celiac artery are atherosclerosis or median arcuate ligament compression. Median arcuate ligament syndrome is a rare example of stenosis of the origin of the common hepatic artery. The obstruction is caused be a fibrous arch crossing the aorta usually superior to the celiac artery takeoff and at the level of the insertion of the diaphragm bridging the crura. The median arcuate ligament crosses in front of (anterior to) the celiac artery in an estimated 10-24% of asymp individuals and ~1% of these individuals exhibit severe compression assoc with symptoms. The syndrome most commonly affects patients 20-40 yrs old and is more common in women, particularly thin women. A replaced R hepatic artery in which the artery does not arise from the celiac axis but from the SMA (type 3), is 1 of the most common variants occuring in 11-21% of pts. The RHA usually passes lateral to and behind the portal vein and enters the hepatoduodenal ligament posterolateral to the bile duct. It can be felt in this location when palpating the structures at the porta with the finger in the foramen of Winslow. During a Whipple, a replaced R hepatic should be preserved. The R system is the chief source of blood supply to the bile duct but its ligation would not diminish flow to the common hepatic artery. An acceossory RHA runs along the same course as a replaced RHA (type 6) but can be ligated without incident. A relplaced L hepatic artery also referred to as the type 2 variant in the Michel classification is characterized by the LHA originating from the L gastric artery and is seen in 3.8-10% of pts. This artery can usually be readily identified and spared during Whipple. An accessory LHA runs along the same course as a replaced LHA (type 5) but can be ligated without any major problems. Occlusive disease within the SMA will stimulate the development of collateral flow from the celiac trunk through the pancreas. Division of the GDA and removal of the head of the panc in this case could result in bowel ischemia but no reduction in flow to the liver via the hepatic artery.

Answer 558

E Divide cysts into serous, mucinous, and indeterminate lesions and use size to trigger surgical resection; size is considered a surrgoate for risk of malignant progression in the case of mucinous cysts (MCN, IPMNs). Clinical hx to r/o recent pancreatitis. Then evaluate cystic panc lesion with high quality cross sectional imaging with a multidetector CT that allow thin section scanning of the panc. This imaging can provide excellent visualization of septa, mural nodules, and calcifications within or adjacent to the cyst that suggest premalignant or malignant cysts. Performed and interpreted correctly, CT imaging can identify serous cystadenomas requiring surgery only for symptoms or evidence of tumor mass effect. This pt presented with a 2 cm cyst and no other changes on CT so the risk of malignancy is low. According to current criteria, this pt does not require sx, even if this were a mucinous tumor MRCP also provides excellent characterization of cyst morphology in cytsts >4 cm but is not useful for smaller cysts. Endoscopy with or without ERCP has a limited role in the evaluation of panc cysts, but these tests may be useful in the eval of suspected IPMN that involves the main panc duct. Mucin emanating from the ampulla in the setting of a dilated panc duct is assumed to be dx of main duct IPMN and can be visualized easily at the time of endoscopy. IN addition, ERCP often can identify intraductal papillary excrescences characteristic of IPMN and may allow documentation of the communication between the panc duct and major cyst component. If this pt has an IPMN tumor, it is of hte side branch variety for which this test is not necessary. EUS +/- cyst aspiration is a valuable tool in the assessment of cysts that are of intermediate significance on cross sectional imaging. This test is highly operator dependent but the info gained from EUS by an experienced gastroenterologist can be very valuable. EUS can provide detailed images of the cyst wall as well as internal cyst architecture; however, limited data indicate that EUS without bx will change the mgmt in a majority of cases, such as that presented, who have received adequate cross sectional imaging. In cases that are indeterminate fro mucinous or serous nature after imaging. EUS guided FNA bx can add useful info. The fluid obtained by EUS FNA can be used for cytologic analysis as well as for analysis of various tumor markers. The diagnostic utility of cyst fluid analysis is related to a variety of tumor markers including CA 19-9, CEA, cancer antigen 15-3. M1 mucin and amylase. The most consistent results were reported for cyst fluid CEA levels. An elevated cyst fluid CEA is a predictor of a mucinous lesion but is not predictive of malignancy without mucinous cysts. Serous cystadenomas and retnetion cysts also have uniformly undetectable CEA levels in cyts fluid. This case represents an incidentally identified 2 cm cystic lesion in the pancreas The lesion could be serous (nonmalignant) or mucinous (premalignant). If mucinous, the small size, makes the risk on noninvasive malignancy low and surgical resection will not be indicated. EUS guided FNA could be used in this case to determine serous vs mucinous nature;however, this would not change the indication for surgical resection unless further RFs are identified (malignant cells in aspirate, solid tumor within cyst)

Answer 559

A Surgical resection is a safe and effective tx for hepatic CRC mets. Resections can be accomplished with an operative mortality <5% even for resection of up to 80% of the liver. Such resections resulted in 5 yr survival for more than 1/3 of pts even the in era of before established adjuvant chemo. With modern adjuvant tx, these resections provide 5 year survival of nearly 60%s. Currently hepatic CRC mets are considered resectable if disease can be completely resection, 2 adjacent liver segments are spared, adequate vascular inflow and outflow and biliary drainage can be preserved, and volume of the liver remaining after resection will be adequate. In pts with N parenchyma, acceptable FLR should eb ~20-25% or the equivalent of a minimum of 2 segments. IN pts without N liver parenchyma, FLR ranges from 30-60% in pts with chemo steatosis or hepatitis and from 40-70% in cirrhosis. Most patients with CRC will receive oxaliplatin base therapy. Oxaliplatin is assoc with a high rate of sinusoidal injury. The observed injury is oxaliplatin specific, b/c liver specimens from chemo naive patients and those from pts receiving preop tx with other chemo agents (i.e. irinotecan or 5 FU) demonstrate lower rates of sinusoidal injury. Incr in spleen size correlate with incr grade of hepatic sinusoidal injury and can serve as a simple method of identifying pts at risk for this toxicity. Oxaliplatin induced enlargment of the spleen should be recognized as a potential etiology of persistent thrombocytopenia after oxaliplatin tx In pts with CRC mets undergoing hepatic resection after oxaliplatin based chemo, the development of hepatic sinusoidal injury correlated with incr morbidity. R heart failure results in dilated sinusoidal veins rather than obliterative injury Repeated or chronic liver injury can result in progressive fibrosis of liver parenchyma (bridging fibrosis being the most severe), liver cirrhosis, and portal HTN. The N hepatic venous pressure gradient is 1-5 mmHg. A gradient of at least 10 mmHG is clinically significant portal HTN and is predictive of complications of cirrhosis. Pts with liver cirrhosis have an incr risk of mortality after resection, with some series reporting the mortality risk to be as high as 20%. In addition to an overall operative risk, cirrhosis, results in a higher probability of liver failure and is assoc with reduced regeneration after hepatectomy

Answer 560

D IPMN is a distinct entity characterized by papillary proliferations of mucin producing epithelial cells with excessive mucus production and cystic diln of the panc ducts. IPMNs have malignant potential and exhibit a broad histologic spectrum, ranging from adenoma to invasive carcinoma. Rate of progression to carcinoma appears to be slow. IPMN pts have a favourable prognosis if appropriately tx. 2/3 of IPMN pts are men. Peak age is 6th decade. Most pts have long standing hx of recurrent acute pancreatitis or symptoms suggestive of chronic obstructive pancreatitis due to intermittent obstruction of the panc duct by a mucus plug. Common cause of exocrine insufficiency and resultant wt loss. Other less common symptoms incl diabetes, jaundice, and back pain. However, many pts are asymp. In such pts, IPMN is detected incidentally during imaging studies for other diseases. Presence of mucin within a dilated duct is dx of main duct IPMN. IPMN are categorized according to involvement of the main duct or side branches (or mixed variant) of the panc ductal system. Main duct IPMN carries a higher risk of malignancy than side branch IPMN. In large series of surgically resected main duct IPMN, approx 70% of tumors harbor malignancy (invasive or noninvasive), with approx 45% of all pts demonstrating an invasive carcinoma in the specimen. Presence of symptoms, main duct panc duct diameter 15 mm, and mural nodules were all significant predictors of malignancy in the main duct or mixed IPMNs, although pts without nodules or such marked panc duct diln had in situ or invasive carcinoma. In the absence of mural nodules or a panc mass on imaging, the risk of invasive malignancy in this pt is likely <40%. Current recommendation is to resect all main duct and mixed variant IMPN as long as the pt is a good surgical candidate with a reasonable life expectancy. Resection is performed b/c of the high risk of occult malignancy within the main duct, so indication for sx strengthens with incr main duct diameter (>10 mm) or the presence of nodules or masses within the duct. Cross sectional imaging may not detect small masses, so duct size is the dominant factor. Serum Ca19-9 can be elevated and can be useful marker in pts with noninvasive cancer but is usually unhelpful in pts with IPMN. There is no role for drainage procedures as cause of obstruction is mucin from transformed cells within the main duct and not stricture or stones.

Answer 561

E Pts with complicated appy can be initially managed with perc drain of RLQ abscess and abx tx. Conservative mgmt of pts who have an appy abscess is assoc with less morbidity and a decrease LOS in hosp compared with pts undergoing acute appendectomy. Which clinical improvement in pt's exam and labs, pts are d/c'ed from the hosp without appy performed. If the pt has not clinically improved, operative intervention is appropriate. This patient, has a N abdo exam and WBC. Repeat imaging is not indicated in the asymp pt. Interval appy, once considered routine is not longer justified; recurrent appy rates reported between 5 and 7% and interval appy complication rates are between 2% and 23%. Pts should be counselled about the S and S of recurrent appy and encouraged to seek medical attn early should such symptoms occur. 3 studies support follow up scope in pts older than 40 yrs who are managed conservatively to exclude coexistence disease or CRC. Observation alone may be considered in younger pts, but this 48 year old pt should undergo colon screening

Answer 562

C The term abdominal compartment syndrome is used to describe the constellation of end-organ physiologic derangements caused by an acute incr in intra-abdominal pressure. Although most often described in the multiply injured trauma patient, abdo compartment syndrome may occur in any pts after massive crystalloid and blood product resusc. Intra-abdominal HTN (IAH) is caused by resusc assoc bowel edema, RP edema, and large quantities of ascitic fluid. Clinical indexes of end organ derangement, such as decr UO, incr pulm pressures, decr preload, and cardiac dysfunction. Dx of IAH is obtained by measuring the pt's bladder pressure. No single pressure measurement mandates intervention, although any intra abdo pressure >20 cm H2O is worrisome. Rather, the combo of the bladder pressure measurement and end organ sequelae (decr UO, incr pulm pressures or decr CO) is required for the dx for abdo compartment syndrome. If the pt has abdo compartment syndrome, emergent decompression is indicated; mortality is directly affected by decompression. Decompression by midline exp lap. Patients with significant intra-abdo fluid as a component of abdominal compartment syndrome may be candidates for decompression via a perc drain. Determined by bedside US. Removing a significant amt of ascites via the perc drain can lower intra abdo pressures . If it does not result in a significant drop in intra abdominal pressures and are assoc with improvement of the pt's physiology, decompressive laparotomy should be performed.

Answer 563

E Majority of PMP originate from ruptures low grade appendiceal tumors. Some arise from other organs such as ovarian mucinous tumors. Rare disease with an estimated incidence of 1 per million population per year. Clinical presentation of PMP of appendix is most common with suspected appy, incr abdo distension or new onset hernia. Most pts are dx at a laparotomy performed for suspected appy, peritonitis or gyne cancer. Preop work up of known or suspected PMP should include abdo and pelvic CT to assess operability. Laparoscopy can be used to assess peritoneal surfaces and stage the disease to select surgical candidates. Lab work up should include CEA. In women, CA 125 may be useful to differentiate between ovarian cancer and PMP Cytoreductive surgery along with perioperative locoregional chemo have been shown to improve survival. Sx is expensive, time consuming and high risk

Answer 564

C Puestow limited to pts with dilated pancreatic duct, meaning that a substantial number of pts with chronic pancreatitis were not eligible for surgical therapy. Early pain relief in 80%, nearly 30% of these pts developed recurrent pain within 3-5 years. Pain recurrence was attributed to persistent or recurrent disease in the panc head with inadequate drainage of the proximal wirsung and tributary branches in the uncinate. Various techniques developed included Whipple, duodenum preserving panc head resection (Beger), and local resection of panc head with longitudinal pancreaticojejunostomy (Frey). Studies comparing whipple, beger and Frey. Similar pain relief between 1-4 yrs, regardless of technique, with approx 80% repeorting complete or significant pain relief. Long term results shows 80% pain relief at median follow up of 8.5 years. Long term results for resectional techniques are significantly better than those for the Puestow. Studies of total pancreatectomy with or without islet cell autotransplantation, reported pain relief in 80-85%, suggesting that it is no better than the other resectional techniques but does have improved results compared to the Puestow. RCT comparing panc duct stent with or without lithotripsy vs surgical drainage of the panc duct show that surgical drainage was more effective than endoscopic therapy in tx pts with chronic pancreatitis and a dilated panc duct. Complete or partial pain relief was seen in 32% of pts tx endoscopically vs 75% of pts have surgical therapy during 2 yrs of follow up

Answer 565

B When CBD stones are identified on cholangiography during the course of lap chole, the surgeon has several options. Open CBD exploration, lap CBD exploration via the cystic duct (stones <1 cm in diameter), lap CBD exploration via choledochotomy or post op ERCP with stone extraction. Post op ERCP is more cost effective than open CBD exploration but less cost effective than lap CBD exploration performed at time of chole. ERCP in this setting is more than 90% successful at clearing CBD. If the first ERCP attempt is unsuccessful, a repeat attempt is worthwhile. Overall complication rate after ERCP in this setting is 5-7%. 30 day mortality rats range from 0.1-0.5% in large series. Pancreatitis occurs in 5-10% of pts after ERCP with stone extraction and necrotizing pancreatitis in 0.7%

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