Surgery Flashcards
(157 cards)
1
Q
most common metastasis sites of adrenal tumors?
A
Think L3 Liver Lung Lymph Bone
make sure to scan for all these if carcinoma
2
Q
Classification of a adrenal adenoma?
A
Size is <4cm Regular shape and borders Contrast was out is > 50% after 10 min CT attenuation is < 10 HU MRI showes same shade as liver both in T1 and T2
3
Q
Classification of a Adrenal Carcinoma?
A
Size > 4cm
Irregular shape and infiltrating borders
CT attenuation is > 20 HU
Contrast washout < 50% at 10 min
Increased vascularization
Calsification
MRI hypointense (black) compared to liver in T1
4
Q
how can you confirmed it the adrenal carcinoma is a primary of metastatic tumor?
A
Take a FNAB
5
Q
Process of deciding treatment of adrenal tumor
A
- is it functional or not (hormones)
- Overnight dexa test ( > 1.8ug/dl in morning is confirming)
- measure metanephrins in 24h urine (pheo)
- SURGERY
6
Q
what is the surgical procedure in Adrenal tumor? when do you wait and when do you to in asap?
A
If non functional you monitor for 6-12 months, if it grows more then 1cm you remove
If it is a producing tumor then remove asap with No touch tech.
7
Q
what to do before removing a pheo tumor?
A
2-3 weeks before - give A-blockers
2-3 days before - give B-blockers
right before - give glucocorticoids
8
Q
location and bloodsupply of the adrenals?
A
12th IC space
- sup. suprarenal ( inferior phrenic)
- middle suprarenal (direct aorta)
- inferior suprarenal ( renal a.)
9
Q
diseases caused by actively secreting adrenal tumor?
A
Conns (aldosteron)
Cushings (cortisol)
Pheochromocytoma (NE/epi)
10
Q
contraindications for laparoscopic adrenalectomy?
A
tumor > 9cm
local invasive tumor
general contraindications for laparoscopic surgery
11
Q
what is goiter?
A
irregular growth of the thyroid, either overall enlargement or nodules
12
Q
symptomes of HYPERthyroidism
A
- weightloss
- tachycardia
- palpitations
- arrhythmias
- irritability, anxiety, nervousness
- heat sensitivity
13
Q
symptomes of HYPOthyroidism
A
- weight gain
- bradychardia
- dry skin
- constipation
- fatigue, muscle loss
- puffy face
- hoarsness
- cold sensitivity
14
Q
Ethiology of goiter?
A
- iodine deficiency
- Graves
- Hashimoto
- DeQuervian (subacute)
- tumor
- pregnancy
- Riedel thyroditis
15
Q
types of Goiter?
A
Diffuse: symetric enlargment
Nodular: non symmetric enlargment
16
Q
causes of nodular goiter
A
Thyroiditis
Graves
hypothyroidism
17
Q
causes of diffuse goiter
A
cysts
autonomous nodules (adenomas)
degenerative nodules
tumors
18
Q
Diagnosis of goiter
A
anamnesis physical examination, palpitation sonography lab tests CT MRI FNAB
19
Q
sonography findings in goiter - Benign lesions?
A
Hyperechoic/anechoic Halow sign Peripheral calcification < 1cm peripheral vascularization
20
Q
sonography findings in goiter - Malignant lesions?
A
Hypoechoic Star-sky calcification in nodule No halow sign > 2cm intranodal calcification
21
Q
Define hypoechoic US?
A
darker then surrounding tissue but NOT black like vessles
22
Q
define anechoic and hyperechoic?
A
Anechoic is black like vessles
Hyperechoic is white/lighter then surrounding tissue
23
Q
the strong 3 indications of malignant thyroid nodules?
A
- > 2cm
- calcification
- Solid structure
24
Q
Types of thyroidectomy
A
- Lobectomy (one lobe)
- Hemithyroidectomy (lobe and ishtmus)
- Total thyroidectomy
- subtotal (leave 4g on each side to save nerve)
- Near total (leave 2g on each side)
- Heartly Dunhill (leave 4g on ONE side)
25
riskfactors of thyroid cancer?
radiation
family history
> 65 years
26
physical examination indications of thyroid cancer
```
Nodules in patient < 25 yrs
Dysphagia
Hoarsness
Firm on palpitation and not moving
swollen, painless lymph nodes on one side
```
27
Diagnosis of thyroid nodules?
1. Examination
2. US
3. Lab tests
4. Scintigraphy (I-isotope uptake test with I133)
5. FNAB
28
Thyroid scintigraphy procedure and results?
Give I-133 to patient, then use Gamma camera to look for nodules taking up the iodine, they will become darker if active and have no colore if not active
Active:
One nodule = toxic adenoma
multiple nodules = Multinodular Toxic goiter
Non-active:
High risk of malignancy - do FNAB of ALL nodules and US tripple positive sign
29
origin of thyroid tumor cells?
mostly from follicular cells except medullary which is from parafollicular C-cells
30
Types pf thyroid cancers?
Papillary 70% good prognosis
Follicular 20% good prognosis if removed
Anaplastic 5% poor prognosis
Medullary 2% Poore prognosis
31
what is spescial with the anaplastic thyroic cancer?
undifferentiated highly agressive cancer, no response ro RAI
32
morphology of papillary thyroid cancer?
often cystic with fibrosis and calcification
diagnosis based of orphan annie nucleus ( clear)
nuclear invaginations
can have papillary architecture
psammomma (calcified) bodies
33
metastasis nature of follicular thyroid carcinoma
hematogenous to liver, lung and bone, not lymph like papillary form
34
occurance of medullary thyroid cancer
mostly sporadic if not they are ass. with MEN 2a/2b and the person will have other cancers ass cell
35
nature of cells in medullary thyroid cancer?
they are spindle shaped neuroendocrine cells derived from the parafollicular C cells and secrete calcitonin BUT hypocalcemia is not present
36
anaplastic thyroid cancer comed from?
belived to be dedefferentiation of an already ongoing cancer ex. papillary. agressive with 100% death rate within 1 year
37
which thyroid cancer is most sees in young people?
papillary can happen at young ages as well
38
causes of Hyper parathyroidism?
adenoma (95%)
Primary hyperplasia
parathyroid carcinoma (1%)
39
pathogenesis of parathyroid tumor genes?
D1 cell cycle regulator relocation on the 11 chromosome to PTH gene expression site
MEN1 tumor supressor gene mutation
40
what can HPT due to bone?
increased metabolist by OC
| in severe cases osteitis fibrosa cystica
41
HPT in GI?
```
constipation
neausea
peptic ulcers
pancreatitis
gallstones
```
42
HPT in kidney?
polyuria
| kidney stones
43
lab diagnosis of PHPT?
| Imaging?
high PTH
high Calsium
Calciuria > 400mg/day
Scintigraphy with Tc-99m sestamibi washout method SPECT
MRI
44
treamt ment rules in HPT?
1. Ca < 3.0mg/L and no symptomes = no treatment
2. Ca - 3.0-3.5mg/L and no symptomes = no treatment but hydration
3. Ca - 3.0-3.5mg/L but symptomes = must treat
4. Ca > 3.5 = must treat regardless of no symptomes
45
What is the definit treatment for PHPT?
| in first line is contraindicated then pharmacologic treatment of HPT?
THE ONLY CURATIVE TREATMENT FOR PHPT IS SURGERY
```
IF CONTRAINDICATED:
Bisphosphatases
Denosumab
Calcitonin
Loop diuretics (increase kidney excretion)
Glucocorticoids (GI untake decrease)
```
46
what must you do before parathyroid gland surgery?
you have to localize the 4 grands
1. US
2. Scintigraphy SPECT
3. CT
3. MRI
5. selective arteriography
6. selective venous sampling
7. methionine PET CT
8. SPECT-CT
47
the 10 rules of parathyroid by J. Norman
1. NO drugs can cure
2. all have symptomes
3. symptomes not correlated with Ca2+ level
4. all patient have Ca and PTH fluctuations
5. all get osteoporosis
6. drugs will not help bones in long run
7. gets worse over time
8. only treatment of PHPT i surgery
9. mininal invasive surgery can cure all
10. sucsess rate repends on surgeon skills
48
surgical approach in PTH surgery
1. Bilateral exploration without localization - this is a open surgery and the most used type, where the surgeon does not know where the glands are before surgery
2. Unilateral ecploration after preopeative localization
3. minimal access surgery with pre and intraoperative diagnostic procedure.
this one can be converted to open surgery during procedure if the level of PTH is not decreased during operation
49
How do we measure intraoperativly the PTH leven during minimal access surgery?
we measure the level at the beginning of surgery. The half life of the PTH is 5 minutes so measuring the level of PTH in veins after 10 minutes should show a decrease
50
etiology of GERD
1. hyperacidity ( Zollinger-Ellison, H. pylori, hypergastrinemia
2. Smoking (relaxes LES)
3. obesity
4. Pregnancy
5. Alcohol
6. Hiatal hernia
51
diagnosing GERD?
1. endoscopy
2. esophageal pH monitoring
3. barium swallow test
4. esophageal monometry (strength and muscle coordination of your esophagus)
52
treatment of GERD
1. PPI
2. H2I
3. lifestyle
4. Fundoplication
5. endoscopic mucosectomy
53
Fundoplication surgery?
part of stomach fundus is pulled up and secured around the lower esophagus. causing stronger LES.
54
Endoscopic mucous resection in GERD
we go in through the mouth down to esophagus, sucks mucous and submucousa into endoscope device. puts ring around creating pollyp and cuts it off.
55
GERD complications
1. barret
2. refluc esophagitis
3. esophageal strictures and schatzki rings
4. aspiration pneumonia
56
Saint triad
combination of cholelithiasis, diverticulosis, hiatal hernia (seen in 1.5%)
57
diagnosis of hiatal hernia
1. barum swallowing test
2. endoscopy (check Z line - squamocolumnar separation of esophaugus and stomach)
3. CXR
4. CT
5. esophageal manometry
6. pH monitoring
58
treatment of hiatal hernia
1. open fundoplication and hiatoplasty
| 2. gastropexy/fundopexy if type II, III, IV
59
what is gastropexy
Gastropexy is a surgical operation in which the stomach is sutured to the abdominal wall or the diaphragm.
60
cause of zenkers diverticulum
impaired relaxation of cricopharyngeal muscles
61
location of zenkers diverticulum?
killians triangle
62
classification of esophageal divertcula - location
UED - killians
MED - trachea biforcation
LED - epiphrenic
63
classification of esophageal divertcula - histology
TRUE - all layers
| FALSE - mucosa and submucosa
64
classification of esophageal diverticula - pathophysiology
Pulsion - increased intraluminal pressure, only mucosa and submucosa
Traction - scarring and retraction from inflammation, with all layers involved
65
treatment of esophageal diverticulums
SURGERY
1. zenker: cricopharyngeal myotomy
2. epiphrenic: esophageomyotomy
NON-SURGIAL IF CI
1. botox + PPI
66
what is achalasia?
motility disorder of the esophagus due to inadequate relaxation of LES and destruction of inhibitory neurons causing loss of peristalsis
67
ethiology of secondary achalasia
1. esophageal cancer
2. gastric cancer
3. chagas disease
4. amyloidosis
5. neurofibromatosis type 1
6. sarcoidosis
68
achalasia treatment
1. pneumatic dilation with ballon in LES
2. LES myotomy (HELLER)
3. if CI surgery then botox and CCB
69
esophageal injuries
1. fistula
2. esophageal web
3. diverticulum
4. mallory-wess
5. varices
6. achalasia
7. barret esophagus
8. GERD
9. perforation
70
boerhaave syndrom?
spontaneous rupture of the esophagus. can be seen in mallory-wess syndrom
71
treatment of esophageal rupture
1. stabilization: IV fluids, electrolytes, AB
| 2. surgery: suture, muscle or pleural flap, fundoplication, resection, delayed reconstruction
72
location of peptic ulcers
stomach and duodenum
73
difference between erosion and ulcer?
ulcer involves more the the muscularis mucosa
74
surgical treatment for peptic ulcers
1. vagotomy
| 2. partial gastrectomy (billroth)
75
types of partial gastrectomy - Billroth I
Billroth I
distal gastrectomy with end-end or side-end gastroduodenostomy by removing gastric atrum and pyloris and the duodedal loop is freed from the peritoneum and sutured together
76
types of partial gastrectomy - Billrot II
lower 2/3 of stomach is removed and the duodenum is left with a stump end. The remaining stomach is sutured to jejunum - gastrojejunostomy in a side-side manner (prevents bile to enter stomach)
77
total gastrectomy with Roux-en-Y anastomosis?
remove stomach except cardia and funcus. cut dudenum and leave stump end, other end is sutured to lower down jejunum in a end-side manner. The upper jejunum is sutured to stomach in a side-side manner
78
Virchow's node
An enlargement of a supraventricular lymphnode can be the first sign of gastric cancer due to the association between left supraclavicular lymphadenopathy and gastric cancer.
79
paraneoplastic signs of gastric cancer
seborrheic keratosis
acanthosis nigricans
thromboplebitis migricans
80
drug in HER2 positive gastric cancer?
traztuzumab
81
drug treatment with TK inhibitor is GIST?
imitinib or dasatinib
82
surgucal treatment of GIST?
tumor < 2cm - drugs and observe
| tumors > 2cm surgical excision + drugs
83
gastric tumors?
```
adenocarcinoma
GIST
MALT
neuroendocrine tumor
sarcoma
```
84
post gastrectomy complications
malnutrition
dumping syndrom (early/late)
reoccurance of cancer
85
what i early dumping syndrom?
```
premature gastric emptying with early symptomes (10 min) causes water do be pushed fro blood into bowel to dilute causing distention of bowel.
Hypotention
bloted
cramps
diarrhea
```
86
what is late dumping syndrom?
premature gastric emtying with late symptomes (1h). Increased sugar absorption trigger increased insulin release causing hyperglycemic induced hypoglycemia
87
Murphy sign
Murphy's sign is elicited in patients with acute cholecystitis by asking the patient to take in and hold a deep breath while palpating the right subcostal area. If pain occurs on inspiration, when the inflamed gallbladder comes into contact with the examiner's hand, Murphy's sign is positive.
88
CI for cholecystectomy?
1. hemodynamic unstable
2. respiratory unstable
3. history of extensive abdominal surgery
4. cirrhosis
5. portal HTN
6. extreme obesity
7. acute phase cholangitis
89
what is MRCP and ERCP (bile)
Magnetic resonance cholangiopancreatography (MRCP) is an alternative to diagnostic endoscopic retrograde cholangiopancreatography (ERCP) for investigating biliary obstruction. The use of MRCP, a non-invasive procedure, may prevent the use of unnecessary invasive procedures.
90
labfindings in cholelithiasis?
Normal
91
Lab findings in choledocolithiasis?
1. high bilirubin
2. high GGT
3. high ALP
4. high ASAT, ALAT
92
Lab findings in cholecystitis
fever
high CRP
high WBC
93
benign liver tumors
1. cavernous hemangiomas
2. focal nodular hyperplasia
3. hepatic adenomas
94
which benign liver tumor should you not take a biopsy from?
hemangiomas due to bleeding risk
95
what does the pancreas do?
enocrine hormones
| exocrine digestive enzymes
96
etiology of acute pancreatitis? I GET SMASHED
```
Idiopathic
Gallstones
Ethanol
Trauma
Scorpion sting
Mumps
Autoimmune
Steroids
Hyper TG an Ca
ERCP
Drugs
```
97
what are the three things happening in pancreas under Acute pancreatitis? and what is the result?
liquification
hemorrhage
Digestion
causes Liquifactive hemorrhagic necrosis
98
external signs of acute pancreatitis?
```
Grey turner sign (hip)
Cullen sign (periumbilical)
```
99
complication in acute pancreatitis?
1. Psaudocyst which can either rupture releasing enzymes causing massive inflammation or become infected by e.coli cuasing abcess
2. bleedign due to destruction of vessle causing hypovolemic shock
3. ARDS
100
surgical treatment of acute pancreatitis?
urgent ERCP, spinchterotomy in choledocolithiasis or cholangitis followed by cholecystectomy
101
cholecystokinin test or secretin test or both together
cerulin or secretin given to patien IV and a tube in duodenum measures secretion of bicarbonate and pancreatic enzymes, low levels proves pancreatin insufficiancy
102
surgical treatment of chronic pancreatitis and why do we want to operate?
surgery is the most effective long term treatment of pain
1. psaudocyst drainage
2. endoscopic stent therapy if obstruction
3. ERCP
4. whippel procedure
103
courvosier sign?
enlarged non-tender gallbladder indicates pancreatic malignancy
104
Trousseau sign
superficial palpable thrombophlebitis ass. with pancreatic tumors
105
Lab markers for pancreatic cancer?
CEA
| CA 19-9
106
Imaging of choice in pancreatic cancer
abdominal contrast CT
107
treatment of pancreatic cancer?
surgery is only curative treatment but can only be done if no metastasis
108
types of surgery in pancreatic cancer?
if tumor is in head: Whippel (pancreas, duodenum and gallbladder removed
if in body or tail: Traverso-longmire (spleen, pancreas and some times duodenum is removed)
109
whats a hemorrhage? when do they become pathological?
normal physiological structures acting as cushions for feces when passing through the rectum. They become pathological when they get swollen
110
what divides the rectum from the anus?
Pectinate or dentate line
111
classification of internal hemorrhoids
1. no protrusion outside
2. protrude but retracts when pressure decrease
3. prolapsed - protrude without retraction but can be pushed in manually
4. . prolapsed - protrude without retraction but can NOT be pushed in manually
112
hemorrhoid complications?
anemia due to bleeding
spinchter spasms causing strangulation and necrosis
thrombotic hernia
113
classification of hemorrhoids based on location?
In respect to the dentate line
1. internal
2. external
3. mixed
114
CT disorders causing hemorrhoids?
Ehlers-Danlos
| Scleroderma
115
Location dependent pain in hemorroids?
external are somatically innervated so they are painfull but external may be painless even though they bleed
116
diagnosing hemorrhoids?
PDE
anoscopy
sigmoidoscopy
barium enema to exclude malignancy
117
treatment of hemorrhoids grade I-II
```
lifestyle
diet
analgestics
topical agents
stool softeners
sitz bath
antispasmodic agents
```
118
hemorrhoid treatment grade III
Rubber band ligation
Sclerotherapy
infrared coagulation
119
Hemorrhoid treatment grade IV
other treatmets have been trie but does not work then we do surgery
1. subcutaneous hemorrhoidectomy
(closed - Ferguson/open - Millian-Morgan)
2. Staple hemorrhoidopexy
120
parts of a staple hemorrhagiopexy?
anal dilator
optorator
sutures
stapler
121
complications of internal hemorrhoids?
prolaps and accumulatin of mucus and fecal debris in external anal tissue - local irritation and inflammation
122
ecternal hemorrhagic complication
thrombosis of the hemorr. causing necrosis of overlying skin and bleeding
123
anal abcess
mostly due to obstruction of the anal glands by debris causing puss filled cavity that most commonly is due to bacteria accumulation and infection in a anal crypt.
124
anal abcess classification
perianal
Ischiorectal
intersphincteric
supralevator
125
anal fistular classification
intersphincter
transsphincter
suprasphincter
extrasphincter
126
what is a anal fistula
connection between an abcess and the anal canal or the abcess to the perianal skin
127
treatment of anal fistulas
1. fistulotomy (most common)
2. seton placement (like a rubber silicon band)
3. fistula plug
128
types of abdominal hernias
1. groin
2. ventral
3. pelvic
4. flank
129
types of groin hernias?
inguinal (direct(indirect)
| femoral
130
location of a direct inguinal hernia?
hasselback triangle
131
ventral henias?
```
true umbilical
peroumbilical
epigastric
spielian (linneasemilunaris)
inscisional
```
132
classification of hernia nature?
1. reducable - can be pushed in
2. incarcerated - cannot be reduced back, risk of infection is higher
3. strangulated - starts as incarserated, no bloodsupply
133
differential diagnosis of hernia
```
hydrocele
varicocele
lipoma
lymphadenopathy
tumor
cyst
```
134
hernial surgery basic classification?
1. open surgery or laporascopic
| 2. transperitoneal/preperitoneal
135
types of hernia surrgery?
herniorraphy
| hernioplasty
136
placement of mesh in herniaplasty?
1. onlay repair - subcutneous
2. inlay repair - between edges of fascia as bridge gap
3. sublay repair - before peritoneum
137
usually we use hernioplasty with mesh what is the CI and what do we use then?
CI if there is an ongoing infection or necrosis of hernia tissue. then we do a herniorraphy surgery
138
laparoscopic procedure in hernia name?
```
transabdominal preperitoneal (TAPP)
total extraperitoneal (TEP)
```
139
umbilical repair of hernia name?
Mayo repair if < 4cm (double suture)
| Mesh closure if < 4cm
140
mechanical wounds
```
inscision
laceration
abrasion
puncture
penetrating
animal bite
gunshot
```
141
N-block removal means?
removal of the tumor and the organs it is involved with
142
markers for bacterial peritonitis with bowel perforation
high ALP and CEA
143
marker for pancreatitis induced peritonitis?
high Amylase
144
what is the most frequent cause of primary peritonitis?
liver cirrhosis with acitis
145
types of appenticitis?
mucous
Phlegmous
necrotic
146
ethiology of appendicitis?
lymphoid proliferation
fecalith
neoplasm
paracite
147
appendicitis tests?
Hamburg - if no loss of appetite then no appendicitis
Blumsburg - rebound tenderness
rosving - contralateral side palpitation increase pain
psoas - flextion pain
adductor flexion pain
148
Alvarao score i apendicitis
| MANTREL-N
```
Migrating of pain
Anorexia
Nausea vomiting
Tenderness in RLQ
Rebound tenderness
Temprature > 38.5
Leukocytosis
Neutropenia
```
149
why is pancreatic transplant so complicated
due to 10 anastomosis sites vs kidney that have 3
150
when do we remove sutures?
5 days normally
| 2 weeks for transplant
151
complications post cholecyctectomy?
bile leakage
| jaundice
152
Anatomical landmark in cholecystectomy?
Calot triangle
153
transplant when malignancy?
5 years after remission and no metastasis
154
gold standar for liver staging?
MRI because cholangio cancinoma shows better in this imaging method so must be done
155
child pugh score?
```
liver staging
billirubin
albumin
prothrombin time
encephalopaty
```
156
liver resection rules
20-35% must be healthy (over 35 if fatty liver)
157
ALPPS PROCEDURE
we want to get hepatotrophy before resection, sp ve ligate portal vein and after 9 days there should be around 10% increase in mass. ligation on side of tumor so health side grows
