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Editors
Robert B. Lim, MD, FACS, FASMBS
A P S y
U S v U v y H hS
Ch , M A v Lp p S y
p A yM C
H ,H

Daniel B. Jones, MD, MS, FACS

P S y
H v M Sh
V Ch S y
O h y I v
Ch , M yI v v S S v
D h B P
B hI D M C
B ,M h

N Y Ch S F L L M M C y
N D h S J S S p Sy y
Copyright 2017 by McGraw-Hill Education. All rights reserved. Except as permitted under the United States Copyright
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T is book is dedicated to my amazing wi e, Lisa. She has given
me the strength and grace to pursue a project like this.
RBL

And to my better hal , Stephanie.

DBJ
This page intentionally left blank
 Contents

Co n t r ibu t o r s 8. A v Lp pyS I
In t r o d u c t io n h R S y
Jigesh A. Shah and Omar Yuse Kudsi
Pr e a c e
Page 28
Ac k n o wl ed g emen t s v
Ethical and Legal Issues 33
Section 1: General Surgery Section Editor: Robert B. Lim
Anesthesia and OR Concerns 3 9. E h /L I D M
Section Editor: Robert B. Lim Steve Alcazar and Shawn suda
1. S p Ap Page 35
Ashley D. Willoughby 10. E L C
Page 5 Jenny Lam and Shawn suda
2. M Hyp Page 37
Harry . Aubin Skin and So issue 39
Page 8 Section Editor: Richard Smith
3. F U S E y 11. S C
F D p A yB p y Jigesh A. Shah and Omar Yuse Kudsi
Paul Wetstein Page 41
Page 11
12. D U
4. A G E Pamela C. Masella and
Roger Eduardo Mark K. Markarian
Page 13 Page 44
Advances in Laparoscopy 17 13. M
Section Editor: Robert B. Lim Amber E. Ritenour and Lauren Greer
5. FLSA P Page 47
Megan Bowen
14. S Ly ph
Page 19
Joshua S. Ritenour
6. A v Lp py NO ES Page 50
Mark A. Gromski and Kai Matthes
15. h S yL
Page 21
C C h
7. R -A S y Ashra A. Sabe
Brenda Schmidt and Gordon Wisbach Page 55
Page 25

vii
vi i i Co n t e n t s

Abdominal Wall, Abdomen, and 28. M U

Gastrointestinal ract 59 Richard M. Peterson
Section Editors: Robert B. Lim, Ronald A. Page 100
Gagliano, Jr., and Richard Smith
29. B S yByp A
16. A W R P
erri L. Carlson Richard M. Peterson
Page 61 Page 103
17. H U /V hC h 30. S v G yL
Richard M. Peterson Alec C. Beekley
Page 64 Page 106
18. A y p I H 31. B p Dv W hD
Lorenzo Anes-Bustillos S h M O y
Page 67 Matthew J. Martin
19. F H Page 109
Harry . Aubin 32. B S y
Page 71 N C p
20. I N Marcos Molina
Harry . Aubin and Eric Balent Page 115
Page 73 33. R v B S y
21. H P ph H Hussna Wakily
Steven M. Henriques Page 117
Page 77 34. A j G B C p
22. A h Ashley D. Willoughby
Mary . ODonnell and E. Matthew Ritter Page 120
Page 79
35. G M
23. G C Douglas Farmer
Brian J. Pottor and Farah A. Husain Page 123
Page 82
36. B yC
24. G S Alexander Malloy
William Cole Page 127
Page 86
37. B y Ch
25. G Ly ph Harry . Aubin
Cletus A. Arciero Page 130
Page 89
38. Ch y P y
26. G ph R D Alan P. Gehrich
Mary . ODonnell and E. Matthew Ritter Page 133
Page 94
39. L v M
27. P P p U D Kevin M. Lin-Hurtubise and Robert L. She er
Henry Lin Page 137
Page 98
 Co n t e n t s ix

40. L v C h 52. C ,R , A R C
Richard Smith Ronald A. Gagliano, Jr.
Page 140 Page 183
41. P P Cy 53. P A
Kiran Lagisetty Alexander Malloy
Page 144 Page 186
42. H P M Breast Disease 189
Richard Smith Section Editor: Richard Smith
Page 146 54. B M
43. Sp /I p h h y p Anita Mamtani
P p Page 191
Ali Linsk and John Paul Sanders
55. D C S
Page 150 Angela Penn
44. S B O Page 195
Patrick Golden
56. I yB C
Page 153 Ranjna Sharma
45. I D -I A P Page 199
Bonnie B. Hunt
57. B R
Page 156 Pamela C. Masella and
46. C Mark K. Markarian
Christopher Yheulon Page 202
Page 160 Endocrine Surgery/Head and Neck
47. M I h umors 207
Danielle E. Ca asso Section Editors: Robert B. Lim and Richard Smith
Page 163 58. A G
48. App Yong Choi
Erik Criman Page 209
Page 167 59. Hyp p hy
49. C C Richard K. Inae
Robert B. Lim Page 212
Page 171 60. hy D
50. C h D Richard K. Inae
Andrew . Schlussel Page 215
Page 176 61. P E
51. D v Jigesh A. Shah and
Erik Roedel Omar Yuse Kudsi
Page 179 Page 217
x Co n t e n t s

62. S v y G 72. O h - P v F
Maxwell Sirkin and William J. Jordan
William V. Rice Page 262
Page 221
73. H I j
Pediatric Surgery 225 Ahmed B. Bayoumi, Fares Nigim, and
Section Editor: Mary J. Edwards Ekkehard M. Kasper
63. H N P Page 265
Margaret E. Clark 74. N yHyp /
Page 227 Hyp
Albert Jesse Schuette
64. Py S
Margaret E. Clark Page 279
Page 232 75. Oph h y
Morohunranti O. Oguntoye and
65. H h p D
Robert A. Mazzoli
Mary J. Edwards
Page 282
Page 236
76. h
66. O ph /G h
Booker . King
Paul Wetstein
Page 288
Page 239
77. S p M -O F
rauma Surgery and Critical Care 243
Robert Shawhan, Matthew Eckert, and
Section Editor: Matthew J. Martin
Matthew J. Martin
67. C C R Page 291
B
Matthew Eckert and Matthew J. Martin 78. M j B S I h
ovy Haber Kamine, Stephen R. Odom, and
Page 245
Booker . King
68. K W Page 297
Laura Mazer
79. S N
Page 249
Julia B. Greer
69. P M p G h Page 301
W
Erik Criman and Matthew J. Martin 80. B P
Stephen R. Odom
Page 252
Page 304
70. C v Sp C
Matthew R. Fusco, Ajith J. T omas, and 81. N z F
Christopher S. Ogilvy Allyson L. Berglund and John M. Giurini
Page 256 Page 308

71. M E v I 82. G y
P Peter L. Steinberg
Matthew R. Fusco, Ajith J. T omas, and Page 312
Christopher S. Ogilvy
Page 259
 Co n t e n t s xi

83. F y 93. Ov M
Katherine Carlisle Charles S. Dietrich III and
Page 314 Brad ord P. Whitcomb
Page 353
Section 2: Surgical Subspecialties
94. E p P y
ransplantation Surgery 319 Charles S. Dietrich III and
Section Editor: Ronald A. Gagliano, Jr. Brad ord P. Whitcomb
84. p S yK y Page 358
Joy Sarkar 95. P v I yD
Page 321 Alan P. Gehrich
85. p S yL v Page 362
Joy Sarkar 96. E
Page 324 Alan P. Gehrich
Vascular Surgery 327 Page 366
Section Editor: Dwight C. Kellicut Neurosurgery 369
86. C O Section Editor: Matthew J. Martin
ony Katras 97. B P /S
Page 329 Albert Schuette
87. A A A y Page 371
Dwight C. Kellicut Orthopedic Surgery 375
Page 331 Section Editor: Matthew J. Martin
88. V A 98. C F
Booker . King Justin . Fowler and Justin Robbins
Page 334 Page 377
89. C p H y 99. Sh
Alexander Malloy Kelly G. Kilcoyne
Page 337 Page 380
90. Ly ph D 100. P M
Robert C. McMurray Kelly G. Kilcoyne
Page 340 Page 383
91. V S D 101. K I j
John illou Jeremy McCallum and Douglas Rowles
Page 343 Page 386
92. h O Sy Urology 393
Courtney E. Barrows Section Editor: Joseph R. Sterbis
Page 347
102. N ph h
Gynecology and Obstetrics 351 Peter L. Steinberg
Section Editor: Alan P. Gehrich Page 395
xii Co n t e n t s

103. B C 106. U I j y
Joseph R. Sterbis Raf aella DeRosa and Joseph R. Sterbis
Page 397 Page 405
104. R 107. P C
Joseph R. Sterbis Joseph R. Sterbis
Page 399 Page 408
105. L p
Joseph R. Sterbis Index 411
Page 402
 Contributors

Steve Alcazar Alec C. Beekley, MD, FACS

U v y N v Sh M A P S y
R ,N v Dv A C S y
Dv B S y
Lorenzo Anes-Bustillos, MD S yK M C T J
P S yF U v y
B Ch H p Ph ph , P yv
B ,M h
Allyson L. Berglund, DPM
Cletus A. Arciero, MD, FACS P S
A P S y D p P S y
P D ,B S O yF hp H v V M A ,A
Dv S O y H v M Sh
E yU v yS h M B ,M h
A ,G
Megan Bowen, DO
Harry . Aubin, MD A P
G S yR S y, U H hS v U v y
p A yM C Dv G S y
H ,H S A M yM C
S A ,
Eric Balent, MD
R ,G S y Danielle E. Ca asso, DO, MPH
D p G S y F
p A yM C Dv V E v S y
H ,H N Y -P y H p
W C M
Courtney E. Barrows, MD C U v yM C
G S yR N Y ,N Y
B hI D M C
H v M Sh Katherine Carlisle, MD
B ,M h R Phy ,U y
D p U y
Ahmed B. Bayoumi, MD, MSc p A yM C
Dv N y H ,H
D p S y
B hI D M C
H v M Sh
B ,M h

xiii
xiv Co n t r i b u t o r s

erri L. Carlson, DO Roger Eduardo, MD

R PGY5 R
p A yM C D p S y
D p S y B hI D M C
H ,H H v U v yS h M
B ,M h
Yong Choi, MD, FACS, FASMBS
A P S y Mary J. Edwards, MD
U S v U v y h H hS Ch , P S y
Ch , M yI v v B S y p A yM C
A ,G H ,H

Margaret E. Clark, MD Douglas Farmer, MD, MS

G S yR R
p A yM C G S y, p A y M C
H ,H H ,H

William Cole, MD Justin . Fowler, MD

S R O h p S
G S yD p M A yM C
p A yM C O h p S yS v
H ,H ,W h

Erik Criman, MD Matthew R. Fusco, MD

R Phy ,G S y A P ,N S y
D p S y V U v yM C
p A yM C N hv ,
H ,H
Ronald A. Gagliano, Jr., MD, FASCRS, FACS
Ra aella DeRosa, MD A P S y
U yR C h U v yS h M
p A yM C Ch ,D p S y
H ,H D yH h M G pA z
Ph ,A z
Charles S. Dietrich III, MD
P D , OBGYN R y Alan P. Gehrich, MD, COL, MC
Gy O yS v Ch , F P v M R v
p A yM C S y
H ,H A Ch , D p O /Gy
p A yM C
Matthew Eckert, MD H ,H
A S A P
M A yM C U S v U v y h H hS
,W h W h , DC
 Co n t r i b u t o r s xv

John M. Giurini, DPM Richard K. Inae, MD, FACS, MC, FSs

A P S y G S y
H v M Sh Ch W A yC yH p
Dv P S y F S ,G
D p S yB h I D M
C William J. Jordan, MD
B ,M h S S
S R O h p Sp M
Patrick Golden, DO T W ,
S S
B h A yC yH p ovy Haber Kamine, MD
F C p ,K y Ch R
D p S y
Julia B. Greer, MD, MPH B hI D M C
A P ,M B ,M h
D p M
Dv G y, H p y Ekkehard M. Kasper, MD
N Dv N y, D p S y
U v y P hS h M P h B hI D M C
P h, P yv H v M Sh
B ,M h
Lauren Greer, MD
S S ony Katras, MD, RV , FACS, COL, MC, USAR
p A yM C S V S yC
H ,H p AMC C P S y USUHS
D
Mark A. Gromski, MD USUHS M S S yC hpS
C F V S
G y A v E py S C H p
Dv G y H p y H ,H
I U v yS h M
I p ,I Dwight C. Kellicut, MD, FACS
A P
U S v U v y h H hS
Steven M. Henriques, MD
D p S y
G M yI v v S y
p A yM C
M D S G p
H ,H
M ,F

Kelly G. Kilcoyne, MD
Bonnie B. Hunt, DO A P S y
S yR U S v U v y h H hS
p A yM C D p O h p S y
H ,H W B A yM C
E P ,
Farah A. Husain, MD, FACS, FASMBS
A P ,S y Booker . King, MD, COL, MC
Dv B S v D US A y B C
O H h S U v y US A y I S R h
P ,O F S H ,
xvi Co n t r i b u t o r s

Omar Yuse Kudsi, MD, MBA, FACS Anita Mamtani, MD

A P S y S R S y
f U v yS h M D p S y
B ,M h B hI D M C
H v M Sh
Jenny Lam, MD B ,M h
G S yR
U v y C Mark K. Markarian, MD, MSPH
S D ,C Dv P S y
B ,M h
Kiran Lagisetty, MD
R Matthew J. Martin, MD, FACS, FASMBS
B hI D M C A P S y
B ,M h U S v U v y h H hS
D p S y
Henry Lin, MD, FACS M A yM C
A P J B L -M Ch
U S v U v y h H hS W h
C p ,M C p ,U S N vy
D p H G S y U y Pamela C. Masella, DO
N v H p C pL J p A yM C
C pL J ,N h C H ,H

Kevin M. Lin-Hurtubise, MD, FACS, MAJ, MC, Kai Matthes, MD, PhD
USAR A P A h
Ch , I Rv B , PRMC H v M Sh
A C P S y, J h A. B A j S ,B Ch H p
Sh M (JABSOM) B ,M h
S S O P v P A h
D p S y AMGI M , H
p A yM C
H ,H Laura Mazer, MD, MS
S E F
Ali Linsk, MD D p S y
G S yR S U v y
D p S y S ,C
B hI D M C
B ,M h Robert A. Mazzoli, MD, FACS, COL(Ret), MC
D ,E , ,S ,
Alexander Malloy, DO R
S R D D-VA V C E
G S y Oph h P ,R v, O
p A yM C S y
H ,H A P Oph h y
U S v U v y h H hS
(USUHS)
M A yM C
,W h
 Co n t r i b u t o r s xvii

Jeremy McCallum, MD, CP , MC Angela Penn, MD, FACS

D p S y, O h p D p S y
p A yM C p A yM C
H ,H H ,H

Robert C. McMurray, MD, CP Richard M. Peterson, MD, MPH, FACS, FASMBS

D p G S y A P ,S y
p A yM C Dv M yI v v G S y
H ,H U v y H hS C S A
S A ,
Marcos Molina, MD
R Brian J. Pottor , MD
B hI D M C G S
B ,M h C H h Phy G p
C ,C
Fares Nigim, MD
Dv N y, D p S y William V. Rice, MD
B hI D M C A P D ,G S yR y
H v M Sh W B A yM C
B ,M h A P S y
P LF Sh M
Mary . ODonnell, MD E P ,
Ch R ,G S A P S y
ACS AEI E F U S v U v y h H hS
USUHS h F B h ,M y
W R N M yM C
B h ,M y Amber E. Ritenour, MD, FACS
G S y
Stephen R. Odom, MD p A yM C
A P S y H ,H
D p S y
B hI D M C Joshua S. Ritenour, MD, FACS
B ,M h G S y
p A yM C
Christopher S. Ogilvy, MD H ,H
P ,N y
B hI D M C E. Matthew Ritter, MD, FACS
H v M Sh A P S y
B ,M h V Ch ,E
P D
Morohunranti O. Oguntoye, MD N Cp C G S yR y
C p h v Oph h P D
D p Oph h y ACS A S E /S
M A yM C F hp
,W h T D p S y U S v
U v y h H hS h W R
N M yM C
B h ,M y
xvi i i Co n t r i b u t o r s

Justin Robbins, MD Jigesh A. Shah, DO

O h p S C A ,S y
M A yM C D p S y
O h p S yS v S .E z h M C
,W h f U v yS h M
B ,M h
Erik Roedel, MD
A S Ranjna Sharma, MD, FACS
p A yM C I S y
H ,H H v M Sh
Dv S O y
Douglas Rowles, MD, CDR B hI D M C
D p S y, O h p B ,M h
p A yM C
H ,H Robert Shawhan, MD
S yR
Ashra A. Sabe, MD M A yM C
B hI D M C ,W h
B ,M h
Robert L. Shef er, MD, COL, MC
John Paul Sanders, MD D p y IRB Ch
C RD A yM C C C F y, I M R y
F H , S M O ,D p M
A P S y p A yM C
U S v U v y h H hS H ,H
B h ,M y
Maxwell Sirkin, MD
Joy Sarkar, MD G S yR , PGY4
R S D p G S y
D p G S y W B A yM C
p A yM C E P ,
H ,H
Richard Smith, MD, FACS
Andrew . Schlussel, DO A P ,S y
D p G S y D p G S y
M A yM C U v y H
,W h H ,H

Brenda Schmidt, MD Peter L. Steinberg, MD

D p G S y U ,B h I D M C
N v M C S D A P (S y)
S D ,C H v M Sh
B ,M h
Albert Jesse Schuette, MD, FAANS
N y Ch I v Joseph R. Sterbis, MD
N y P D ,U yR y
W R N M yM C p A yM C
B h ,M y H ,H
 Co n t r i b u t o r s xix

Ajith J. T omas, MD Brad ord P. Whitcomb, MD

A P ,N y Ch
B hI D M C Gy O yS v
H v M Sh p A yM C
B ,M h H ,H

John illou, MD Ashley D. Willoughby, DO

G S yR D p G S y
D p S y p A yM C
B hI D M C /H v H ,H
M Sh
B ,M h Gordon Wisbach, MD, MBA, FACS
A P S y
Mike ran, MD U S v U v y h H hS
S yR F. E H Sh M
B hI D M C B h ,M y
H v M Sh D p G S y
B ,M h N v M C S D
S D ,C
Shawn suda, MD, FACS
A P S y Christopher Yheulon, MD
Ch , D v M yI v v B A P ,S y
S y U S v U v y H hS
U v y N v Sh M B h ,M y
L V ,N v D p S y
p A yM C
Hussna Wakily, MD H ,H
S S
L H M S H p
N Y ,N Y

Paul Wetstein, MD
S yR
p A yM C
H ,H
This page intentionally left blank
 Introduction

A y H h H T .I y .
y y ABSI E - I y h p .I
?T v p p h h q / .T
. y p
T v p hp .
h p p y j . R h , h
R v y p , .I ,y y
h q .T v h p .I j y
h h h h h v h h h y h .
p h p. T h P j y h v .
h p h h
y y p h Daniel B. Jones, MD
.

xxi
This page intentionally left blank
 Pre ace

I v yh h .T B h q G
I v v p y S h q
p h h h y. F h
.I h I v h q ,h h h v -
h p h - y h .T v -
p I h h v h p p h
p y h - h B C h p
.A I p ,I z h p .W h h , h y y
y h h h y
p .T p v .
p v
. Robert B. Lim, MD

xxiii
This page intentionally left blank
 Acknowledgements

T E P h h h v h p v
v h p p :

Chris Barrett, MD
William Cole, MD
James Greenwood
ovy Haber Kamine, MD
Brian Nguyen, MD
Erik Roedel, MD

W z Mike ran, MD h .

xxv
This page intentionally left blank
 SECTION 1

General Surgery
This page intentionally left blank
Anest h esia a nd OR Co nc er ns
Robert B. Lim
This page intentionally left blank
 1
Sleep Apnea

A l y D. W ll ug by

A 54-year-old male presents to his perioperative D. T e critical closing pressure o this patients
appointment to undergo elective inguinal hernia repair. airway is higher than non-OSA patients.
T e patient has a BMI o 38 with a height o 72 in E. T e patient should be placed in the rendelen-
(1.83 m) and a weight o 127 kg (280 lb). He has a his- burg position.
tory o hypertension currently being managed with a
calcium channel blocker. His wi e reports increasing 3. W p lb yw g b
snoring at night with noticeable gasps or air when lying JD R b f mul ?
supine. Patient denies increasing daytime drowsiness. A. 75 kg
He has no history o prior surgeries and no amily his- B. 98 kg
tory o complications with anesthesia. C. 64 kg
On physical exam, he has a neck circum erence o D. 106 kg
44 cm and a Mallampati score o 3. No cardiovascular or E. 86 kg
respiratory abnormalities are observed. His abdomen is
obese with no evidence o caput medusa. Right inguinal 4. W f f ll w g w ul b b p
ring weakness palpated on exam. f p ly g p ?
A. Vecuronium
1. W f f ll w g NOT f B. Cistracurium
b y yp v l y m (OHS)? C. Rocuronium
A. Obesity (BMI > 30 Kg/m 2) D. Pancuronium
B. Neck circum erence o > 48 cm E. Atracurium
C. Daytime hypoventilation
D. Hypercapnia with PaCO2 > 45 mm Hg 5. W f f ll w g u g g p -
E. Hypoxia with PaO2 < 70 mm Hg p v m gm p w up OSA?
A. T e patient should be placed in the supine position
2. W f f ll w g u g g OSA while recovering to protect the surgical site.
p p v p v v lu B. CPAP should be immediately available or use
m g m f p ? in postoperative patients with known or sus-
A. T is patient has 2 out o 3 risk actors or OSA and pected OSA.
there ore does not require polysomnography. C. Opioid dosing should be based on BW rather
B. Face mask pre-oxygenation will create a higher than IBW.
tidal volume than nasal prongs. D. T e use o thoracic epidural post-operatively is
C. T e Mallampati score o 3 is not a risk or a contraindicated in OSA patients.
di cult intubation. E. Use o CPAP post-operatively could increase the
risk o complications.
6 G EN ERAL S U RG ERY EXAM I N ATIO N AN D BO ARD REVI EW
ANSWERS
1. B. Patients with a neck circum erence o > 48 cm
have a high probability o developing obstructive sleep
apnea (OSA); however it is not a criterion or OHS.
OHS results in hypoventilation and hypoxemia due to
the obesity, while OSA is the blockage o airway that
occurs during sleep. Many obese patients have both.
Patients with OHS are at a higher risk or periopera-
tive morbidity and mortality. T ese patients are at a
higher risk o airway collapse, blunted central respira-
tory stimulation, and pulmonary hypertension there-
ore placing these patients at a higher surgical risk.
Criteria or OHS:
a. Obesity (BMI > 30 kg/m 2)
b. Serum bicarbonate > 27 mEq/L
c. SpO2< 93%
d. ABG demonstrating hypercapnia PaCO 2
> 45 mm Hg and hypoxemia PaO2 < 70 mm Hg
e. An alternative cause o hypoventilation cannot
be identi ed
2. D. I the surgery is elective, is likely to require large
doses o anesthetic agent or opioids intraoperatively,
and i there is a high suspicion o undiagnosed OSA
in the perioperative period, it should be postponed
with imminent evaluation and treatment as needed
preoperatively. Evidence has shown that pre-oxygen-
ation via nasal CPAP mask is superior to ace mask
oxygenation, despite potential air leaks i the mouth is
allowed to be open. Nasal CPAP increases the pressure
CLASS 1 CLAS S 2
MALLAMPATI CLASS IFICATION
CLASS 1: Soft palate , fa uce s , uvula, pilla rs
CLASS 2: Soft palate , fa uce s , portion of uvula
CLASS 3: Soft palate , bas e of uvula
CLASS 4: Hard pala te only
gradient between the nasopharyngeal and oropharyn-
geal cavities pushing the so palate and tongue orward
and there ore opening the airway; whereas the positive
pressure through the ace mask will induce an obstruc-
tion. Mallampati score o 3 includes visualization o the
so palate and base o uvula. Mallampati scores o
3 and 4 demonstrate di culty intubation; however
they cannot predict di culty o BVM ventilation.
T e upstream pressure o the pharynx at which air
entry/ ow ceases is considered the critical closing pres-
sure. T is pressure can be increased by increase in lateral
pillar at pads compressing the airway, sleep resulting in
muscle relaxation or induced by anesthesia. T e ideal
positioning or a patient with OSA is the ramped posi-
tion o intubation or the lateral recumbent, i possible
and in reverse rendelenburg position to ease ventila-
tion, increase total lung capacity, and decrease the lon-
gitudinal tension on the upper airway.
3. A. JD Robinson ormula states:
Man: 52 Kg (115 lbs) + 1.9 Kg (4.2 lbs) per inch
over 60 in;
Woman: 49 Kg (108 lbs) + 1.7 Kg (3.7 lbs) per
inch over 60 in.
T is calculation is use ul in this patient to deter-
mine optimal paralytic, anesthetic, and opioid dosing
as well as mechanical ventilation control intraopera-
tively and post-operatively as needed.
4. C. All non-depolarizing neuromuscular blockers
act by antagonizing the acetylcholine receptor in a
CLASS 3 CLASS 4

reversible/competitive manor. A rapid onset, short
acting non-depolarizing agent would be the best
option in this patient. Out o the options listed Rocu-
ronium has an onset o 45 to 60 sec and duration o
30 to 60 min and would be the most ideal. Also obe-
sity has not been ound to alter the pharmacokinetics
o Rocuronium and there ore can be dosed on IBW
or actual body weight. Pancuronium is the longest
acting and is used in patients that require paralysis
> 1 hr and in patients with normal hepatic and renal
unction. Cistatracurium and atracurium undergo
Hof man elimination with an onset o 1 to 2 min and
are intermediate acting. T ese agents would be rec-
ommended in patients with renal or hepatic insu -
ciency. Vecuronium is also an intermediate acting
NMBA and would be recommended in patients with
cardiovascular disease as it has the least adverse side
ef ect pro le. Prolonged duration o paralysis can
occur when using actual body weight in dosing atra-
curium and vecuronium. Avoidance o prolonged
paralysis or large doses o longer acting neuromus-
cular blockers is key.
5. B. CPAP should be available or patients in the
immediate post-operative period i OSA is known
or suspected. I OSA is suspected, introducing CPAP
in the immediate post-operative period can induce
anxiety due to the discom ort o the mask and con-
usion rom the remaining sedatives on board. T e
proper positioning or optimal airway patency is in
the upright and lateral decubitus position i possi-
ble. Opioid dosing should be based on IBW rather
C H AP TER 1 S LEEP AP N EA 7
than BW due to potential or prolonged duration o
action with BW in obese patients resulting in sup-
pression o respiratory drive and decrease pharyn-
geal muscle stimulation. T e use o a post-operative
epidural can be bene cial in patients undergoing a
large abdominal operation at risk or requiring large
doses o opioids or pain control. T e use o CPAP
in the post-operative period has not been shown to
increase complications, speci cally the positive pres-
sure ventilation has not been proven to increase leak
rates in bariatric surgery patients.
BIBLIOGRAPHY
Chau EHL, Mokhlesi B, Chung F. Obesity hypoventilation
syndrome and anesthesia. NIH Sleep Medicine Clinics.
2013; 8(1):135147.
Hillman et al. Obstructive sleep apnea and anaesthesia. Sleep
Medicine Reviews. Elsevier. 2004;8:45971.
Oto et al. Continuous positive airway pressure and ventilation
are more ef ective with a nasal mask than a ull ace mask
in unconscious subjects: a randomized controlled trial.
Critical Care. 2013;17:111.
Puhringer FK et al. Pharmacokinetics o rocuronium bromide
in obese emale patients. European Journal of Anaesthesiology.
1999;16(8):507.
Robinson JD et al. Determination o ideal body weight or
drug dosage calculations. American Journal of Hospital
Pharmacology. 1983; Jun; 40(6):10169.
Schumann R. Anaesthesia or bariatric surgery. Best Practice
and Research Clinical Anaesthesiology. 2011;25:8393.
ietze K. Use o neuromuscular blocking medications in critically
ill patients. http://www.uptodate.com/contents/use-o -
neuromuscular-blocking-medications-in-critically-ill-
patients. J Pharm D. 2013.
 2
Malignant Hypertension

Harry T. Aubin

A 59-year-old emale with poorly controlled hyperten- C. emperature > 38.5

sion on three antihypertensive medications including a D. Pulmonary edema
beta-blocker, angiotensin converting enzyme inhibitor, E. achycardia > 100
and a calcium channel blocker, presents or a routine
surgery. At her preoperative visit, she is instructed to 3. Regarding the medication nitroprusside, which o
hold her home ACE inhibitor the day o surgery. She the ollowing is a eared side e ect with excessive
then undergoes an otherwise uncomplicated cholecys- use?
tectomy with intraoperative cholangiogram. However, A. Cyanide toxicity
in the postoperative care unit, she develops hyperten- B. remor
sion with readings o 200/140. Her other vital signs are C. Stroke
within the normal range. T e anesthesia provider per- D. Myocardial in arction
orms an eye exam and notes papilledema. Nitroprus- E. Angina pectoris
side is administered IV or treatment.
4. Regarding medications to treat malignant hyper-
1. Regarding the immediate management o this tension acutely, which o the ollowing is most
patients malignant hypertension, which o the likely to cause ref exive tachycardia?
ollowing is correct? A. Labetolol
A. Goal BP is reduction to normal rage o SBP B. Hydralazine
< 120, DBP < 80 as soon as possible to prevent C. Metoprolol
stroke. D. Clevidipine
B. Reduction o DBP to 100-105 over 3 hours with E. Fenoldapam
maximum all in BP by 25% over 24 hours is
needed to prevent stroke. 5. Regarding underlying causes o poorly controlled
C. Heart rate control is acutely needed to prevent hypertension, which o the ollowing is the most
worsening cerebral edema. likely cause in this patient?
D. Blood pressure should be maintained at current A. Pheochromocytoma
elevated levels. B. Cushings syndrome
C. Renal artery stenosis
2. Regarding malignant hypertension, which o the D. T yroid storm
ollowing is a clinical sign o this diagnosis? E. Glomerulonephritis
A. Blood pressure > 150/110
B. Papilledema

ANSWERS
1. B. T e goal in malignant hypertension is reduction
in DBP to 100-105 with maximum all in by 25% o
highest BP value over 24 hours. T is slow decrease
prevents re exive vasoconstriction via normal body
auto-regulatory mechanisms leading to stroke. Reduc-
tion o blood pressure to the normal range increases
the risk o stroke and is not recommended.
Heart rate control is not a main goal o care in malig-
nant hypertension. T e mechanism o cerebral edema
is elt to be overcoming the bodys auto-regulatory
mechanism o vasoconstriction with increase in MAP
allowing or a relatively constant end organ per usion
pressure. When BP increases above 180 systolic, auto-
regulatory vasoconstrictions ails, and vasodilation is
seen leading to an increase in blood ow to the brain.
BP control, not heart rate, prevents cerebral edema
by reducing cerebral per usion pressure (intracranial
pressure mean diastolic pressure) and permitting
auto-regulation thus reducing end organ damage.
2. B. Malignant hypertension is de ned by blood pres-
sure > 180/120 with signs o cerebral edema and/or
end organ damage. Cerebral edema is characterized
by clinical signs o brain swelling. Papilledema is the
most worrisome sign. However, retinal hemorrhages
and retinal exudates are indicative o hypertension
causing damage to arterioles and capillary beds. Other
end organ ndings include acute kidney injury, myo-
cardial in arction, aortic dissection or bowel ischemia.
achycardia is not a criterion or diagnosing
malignant hypertension. achycardia is commonly
seen in postoperative patients and could be attrib-
uted to catecholamine release rom the stressors o
surgery, pain, intravascular depletion, medications,
arrhythmias, and/or atelectasis. Its presence necessi-
tates close observation and thorough work-up.
3. A. Nitroprusside is an artrio-venous dilator that has
rapid onset and short hal -li e. It, as well as ast act-
ing medications like clevidipine, nicardipine, labeto-
lol, and enoldapam, are used or acute treatment o
hypertension. With over administration o nitroprus-
side, cyanide toxicity can develop as this medication
contains cyanide groups (carbon triple bonded with
nitrogen). Cyanide toxicity is detrimental to aerobic
metabolism at the cellular level by inhibiting the last
enzyme in oxidative phosphorylation, cytochrome
oxidase (a3). Cyanide toxicity can present with
headache, nausea, emesis, and ushing, hepatic and/
C H AP TER 2 MAl i g n An T H y P ERTEn s i o n 9
or renal ailure. T e treatment o cyanide toxicity is
multimodal and includes sodium nitrite, hyperbaric
oxygen, and sodium thiosul ate.
remor is not a known side e ect o nitroprusside,
but hypere exia is commonly seen in toxic levels o
this drug leading to cyanide toxicity.
Stroke, myocardial in arction, and angina pectoris
are not published side e ects o nitroprusside. T ese
are more characteristic o malignant hypertension
itsel due to end organ damage rom capillary and
arteriole damage to the heart.
4. B. Hydralazine is a direct arteriolar vasodilator. It
has rapid onset and short hal -li e administered
IV. It can commonly cause re exive tachycardia by
two mechanisms. Re exive catecholamine release
in response to vasodilation and decreased vascular
resistance directly stimulates the cardiac myocytes
by beta-1 adrenergic receptors leading to tachycar-
dia. Additionally, due to decrease in renal blood ow,
the juxtaglomerular apparatus secretes renin leading
to increased aldosterone secretion. Aldosterone is a
potent vasoconstrictor that decreases venous return.
As a compensatory mechanism, heart rate increases
to compensate and keep cardiac output constant (CO
= HR SV). Re exive tachycardia is commonly
seen in patients who are not concomitantly on beta
blockers and angiotensin-converting enzyme (ACE)
inhibitors.
Labetolol is both and alpha-1 and beta-1 antago-
nist. It has rapid onset and is ideal or patients with
tachycardia and some hypertension. It does not
cause re ex tachycardia due to inhibition o beta-1
receptors.
Metoprolol is a beta-blocker and will decrease
heart rate. It is ideal in atrial brillation, with little
e cacy in malignant hypertension.
Clevidipine is a dihydropyridine calcium channel
blocker. It has rapid onset, very short hal -li e, and is
administered intravenously. Because it works periph-
erally, it does not cause re exive tachycardia.
Fenoldapam is a dopamine-1 receptor agonist. It
commonly causes ushing and hypotension. It does
not cause tachycardia because it works peripherally.
5. C. Renal artery stenosis is a common underlying
cause o malignant hypertension and is requently
seen in Caucasians who have poor blood pressure
control despite multimodal therapy. Renal artery ste-
nosis can present as worsening azotemia in relatively
young individuals, poorly controlled hypertension,
10 g En ERAl s U Rg ERy EXAM i n ATi o n An D Bo ARD REVi EW
and/or malignant hypertension. It is diagnosed non-
invasively via renal artery duplex and can be treated
with renal artery stenting. However, this treatment is
becoming more controversial given the recent publi-
cation o the CORAL trial (Hermann SM et al. 2013)
arguing or medical management alone.
Pheochromocytoma is a catecholamine releas-
ing tumor that can cause hypertension. It is usually
episodic and can present with ushing, palpitations,
diaphoresis, and other signs o catecholamine release.
It is diagnosed clinically by history and urine VMAs.
Cushings syndrome can cause hypertension due
to cortisol excess, but is not as common as renal
artery stenosis in malignant hypertension. Conns
Syndrome or hyperaldosteronism is the over pro-
duction o aldosterone by the adrenal gland can also
cause hypertension.
T yroid storm typically presents with tachycardia.
It is treated typically with nonselective beta-blockade
and propylthiouracil (P U).
Glomerulonephritis seen in nephritic syndrome
can cause hypertension and renal ailure. Additionally,
both renal artery stenosis and malignant hypertension
alone can cause renal ailure. However, renal artery
stenosis and not GN is associated with malignant
hypertension.
BIBLIOGRAPHY
Armario P, Dernandez del Rey R, Pardell H. Adverse E ects
o Direct-acting Vasodilators. Drug Saf. 1994; Aug; 11(2):
805.
Davis B, Crook J, Vestal R, Oates J. Prevalence o renovascular
hypertension in patients with grade III or IV hypertensive
retinopathy. N Engl J Med. 1979;301(23):1273.
Hermann S, Saad A, extor S. Management o atherosclerotic
renovascular disease af er Cardiovascular Outcomes in
Renal Atherosclerotic Lesions (CORAL). Nephrology Dial-
ysis Transplant. 2014; Epub ahead o print.
Kaplan NM. Management o Hypertensive Emergencies. Lancet.
1994;344(8933):1335.
Marik PE, Varon J. Hypertensive crises: challenges and man-
agement. Chest. 2007;131(6):1949.
Pasch , Schulz V, Hoppelshauser G. Nitroprusside-induced
ormation o cyanide and its detoxi cation with thiosulphate
during deliberate hypotension. J Cardiovasc Paharmacol.
1983;(5):7785.
Strandgaard S, Paulson O. Cerebral blood ow and its patho-
physiology in hypertension. Am J Hypertension. 1989;
2(6 Pt 1):486.
 3
Fundamentals or Use o
Surgical EnergyFire During
emporal Artery Biopsy
Paul Wetstein
A 74-year-old emale with COPD and a baseline oxygen
requirement presented to the emergency department with
subjective evers, headache, and jaw claudication. Labora-
tory evaluation was notable or an erythrocyte sedimen-
tation rate (ESR) o 56 mm/hr. A non-contrast C o the
head was obtained which revealed no acute pathology. T e
patient was admitted to the internal medicine service and
started on high dose prednisone with a working diagnosis
o giant cell (temporal) arteritis. During a temporal artery
biopsy, an operating room re occurs.
1. Which o the ollowing is correct regarding
operating room f res?
A. wo o the three components o the classically
described re triad must be present or an OR
re to occur.
B. T e most common OR re uel is the monopolar
electrosurgical cautery Bovie.
C. An oxidizer enriched atmosphere o en exists in
the entire operating room.
D. Alcohol containing prep solutions need to be
completely dry be ore starting a procedure.
E. Fiberoptic light sources or endoscopic surgery
do not serve as an ignition source.
2. Which o the ollowing is correct regarding this
scenario?
A. Surgery on the head and neck should be identi ed
preoperatively by the surgeon and anesthesiolo-
gist as low risk.
B. Intraoperative communication between the sur-
geon and anesthesiologist is not needed in a case
o expected short duration.
C. Sedation with open gas delivery device would be
pre erred to general endotracheal anesthesia in
this patient to prevent an OR re.
D. Surgical drapes should be con gured in a manner
as to minimize the accumulation o oxidizers.
E. Moistening surgical sponges has no impact in
preventing an OR re.
3. In the event o f re involvement o the airway or
breathing circuit, the best f rst step is to:
A. Stop the f ow o all gases to the airway.
B. Remove all uels rom the airway.
C. Activate re alarm.
D. Per orm beroptic bronchoscopy with the endo-
tracheal tube in place.
E. Pour saline into the airway.
12 G EN ERAL S U RG ERY EXAM IN ATI O N AN D BO ARD REVIEW
ANSWERS
1. D. In order or a re to occur, all three components
o the re triad must be present. T ese include
uel, and oxidizer, and an ignition source. Fuel or
re is plenti ul in the operating room. Some exam-
ples include drapes, patients hair, surgical gowns,
blankets, endotracheal tubes, and lyngeal mask air-
ways and volatile surgical compounds (e.g., alcohol
containing prep solutions, acetone, etc.). It has been
shown that alcohol containing prep solutions with
as little as 20% alcohol can ignite with diathermy
or hot wire cautery and so they must be allowed to
dry be ore surgical electricity is used. Oxidizers in
the operating room are generally either oxygen or
nitrous oxide. T ese oxidizers can accumulate and
orm an oxidizer enriched atmosphere in closed or
semi-closed breathing systems and rom tenting o
surgical drapes. Ignition sources in the operating
room are equally as plenti ul. Some common exam-
ples include electrosurgical devices, heated probes,
lasers, beroptic light cables, argon beam coagula-
tors, drills and de brillator pads.
2. D. According to the American Society o Anesthe-
siologists 2013 ask Force on operating room res,
an endotracheal tube or LMA should be considered
in patients undergoing moderate to deep sedation
or that have a baseline oxygen requirement. Head
and neck surgery should be considered high risk
or an OR re and as such, communication between
the surgeon and the anesthesiologist is mandatory
regardless o the length o the procedure. Surgical
drapes should be arranged to prevent an accumula-
tion o oxidized air. Moistened surgical sponges can
help prevent OR res.
3. A. Immediate actions to be per ormed in the event
o an airway re include rst removing the endotra-
cheal tube or LMA, then stopping the f ow o ALL
gases, removal o uel sources away rom the airway,
and pouring saline into the airway. Once the re has
been extinguished, actions should include ventilation
o the patient while avoiding oxidizer-enriched envi-
ronments, inspection o the tracheal tube or LMA to
ensure no ragments remain in the patients airway,
and consideration o bronchoscopy. Bronchoscopy is
a relatively sa e procedure in experienced hands in
diagnosing inhalational injury but is not part o the
immediate management o an airway re.
BIBLIOGRAPHY
Ap elbaum JL, Caplan RA, Barker SJ, et al. Practice advisory
or the prevention and management o operating room
res: an updated report by the American Society o Anes-
thesiologists ask Force on Operating Room Fires. Anes-
thesiology. 2013; Feb; 118(2):27190.
Bai C, Huang H, Yao X, et al. Application o f exible bronchos-
copy in inhalation lung injury. Diagnostic Pathology. 2013;
Oct 21:8:174.
Briscoe CE, Hill DW, Payne JP. Inf ammable antiseptics and
theatre res. Br J Surg. 1976; Dec; 63(12):9813.
DeMaria S, Schwartz AD, Narine V, et al. Management o
Intraoperative Airway Fire. Simulation in Healthcare: T e
Journal of the Society for Simulation in Healthcare. 2011;
Dec(6):3603.
 4
Argon Gas Embolism
Roger Eduardo
T e patient is a 37-year-old emale without any signi cant
past medical history undergoing a laparoscopic partial
right hepatic lobectomy or a large symptomatic hepatic
adenoma in segment VI o the liver. Endotracheal intuba-
tion is per ormed without complication and the abdomen
is entered via the Hassan technique. T e lesion is identi-
ed on the in eromedial aspect o segment VI. o dissect
the lesion away rom the liver parenchyma, an argon beam
coagulator is used. wo hours a er the start o the proce-
dure, there is an abrupt decrease in the patients E CO2
rom 30 to 10 mm Hg and spO2 rom 100% to 40%. T is is
rapidly ollowed by a decrease in arterial blood pressure to
60/25 mm Hg and heart rate rom 80 to less than 20.
1. Why is the argon beam coagulator used over other
types of electrocautery?
A. T e ow o gas clears the site o uids and blood,
enhancing visibility.
B. Rapid non-contact uni orm tissue coagulation
over a large area
C. Less adjacent tissue damage rom reduced depth
o penetration
D. Less generation o surgical smoke
E. All o the above
2. What was the most likely cause of this patients
decrease in ETCO2 and arterial blood pressure?
A. Acute myocardial in arct
B. Decreased venous return secondary to pneumo-
peritoneum
C. Aspiration
D. Gas embolism
E. Severe cerebral vascular accident
3. What is the most important factor associated with
an increased risk of venous gas embolism when
using argon beam coagulation?
A. Use under pneumoperitoneum
B. High ow rate o argon gas
C. Holding the tip o the electrode at a right angle to
the tissue
D. Placing tip o argon beam electrode in direct
contact with tissue sur ace
4. What steps can be taken to reduce these risk
factors?
A. Never place the electrode tip less than several
millimeters rom the surgical site.
B. Limit argon ow settings to lowest level that pro-
vides the desired clinical e ect.
C. Move the hand piece away rom the tissue a er
each activation.
D. Flush abdominal cavity with CO2 between
extended activation periods o use.
E. All o the above
5. What would be your next step in management of
this patient?
A. Continue the surgery.
B. Administer atropine and initiate vasopressors.
C. Discontinue pneumoperitoneum and place patient
in Durants position.
D. Per orm emergent EE to diagnose a gas embolism.
E. Begin immediate volume resuscitation.
14 G EN ERAL S U RG ERY EXAM I N ATIO N AN D BO ARD REVI EW
ANSWERS
1. E. Argon beam coagulation has gained popularity
among surgeons as a use ul tool to achieve hemosta-
sis in bleeding sur aces o highly vascularized organs
such as the liver and spleen. It utilizes a monopolar
electrode to partially ionize a stream o argon gas
that is directed towards the tissue or coagulation.
T e ionized argon beam acts as an e cient pathway,
conducting a high- requency electric current rom
the electrode to the target tissue resulting in a ne
spray o electrical sparks.
As the electrical beams directed rom the electrode
to the target tissue causes desiccation, the electrical
conductivity o the targets tissue is lost. I continu-
ally applied, the beams automatically move to nearby
non-desiccated and still electrically conductive tissue
allowing or rapid uni orm coagulation over a large
area without any tissue contact. Furthermore, as a
result o the loss o electric conductivity at a treated
site, the depth o penetration o the electrical energy
is reduced. T is, coupled with the act that the use o
argon gas, due to its inert nature, neither carbonizes
nor vaporizes biologic tissue so that the thermal e ects
are limited, results in less adjacent tissue damage.
2. D. With use o the argon beam coagulation system
in laparoscopic procedures, the argon system acts
as a secondary source o pressurized gas and argon
can accumulate in the closed peritoneal cavity. With
damage to any signi cant blood vessels, the gas under
pressure can enter the vasculature posing a risk o
embolism that could be a mixture o both argon and
carbon dioxide. Moreover, the argon gas stream that
ows between the electrode and the tissue can cross
any disrupted mucosal membrane sur ace and be
ushed directly into the microvasculature.
Although argon is physiologically inert, it is 17
times less soluble than carbon dioxide (0.029 ver-
sus 0.495 ml gas ml1 blood) and as such, argon-rich
emboli are not as readily absorbed rom the blood
stream as CO2 and may pass into the systemic cir-
culation. At the standard ow setting o 4 L/min
used typically or hemostasis in highly vascularized
organs, the argon beam electrode can produce 67 ml
o gas in only one second which, i embolized, can
lead to signi cant cardiopulmonary dys unction
and be potentially lethal in an average size adult.
Furthermore, at such a high ow rate argon gas
clearly exceeds pressure in the venous system and
can embolize not only through major veins but also
through small peripheral veins.
3. D. T e rst ew cases o venous embolism with use
o the argon beam were reported during laparoscopic
procedures and there ore, the theory o over-insuf a-
tion and over-pressurization o the abdominal cav-
ity caused by the accumulation o argon gas under
pneumoperitoneum was thought to lead to these
embolic events. However, given that venous emboli
have occurred in several cases o patients undergo-
ing procedures without pneumoperitoneum, this
theory cannot ully explain the incidence o these
events. Ikegami et al. ( J Hepatobiliary Pancreat Surg.
2009;16(3):3948) compared seven reported cases o
venous embolism using argon beam coagulation and
identi ed the ollowing risk actors:
1. Using the argon gas under pneumoperitoneum;
2. Puncturing the liver parenchyma (hepatic needle
biopsy);
3. Possible injury to the hepatic venous system; and
4. Placing tip o argon beam electrode in direct
contact with tissue sur ace.
On review o the literature, it appears that more
important than the issue o use under pneumoperi-
toneum is that o placing the tip o the argon beam
electrode in close or direct contact with the tissue that
is being treated. Multiple cases have been described,
without the use o penumoperitoneum, where this
is clearly the issue and in the series described above,
though only three cases described this, it is possible
that more might have had this condition and simply
not reported.
When used at ow rates o 0.2 to 2 L/min and a
power o 20 to 80 W as described in the eld o inter-
ventional pulmonology or ablation o small lesions,
the argon beam system can penetrate the tissue up to
5 mm in depth. However, when used or the purpose
o hemostasis in highly vascularized tissues such
as the spleen or hepatic parenchyma, a ow rate o
4 L/min and power o 150 W is typical. T is allows
or even urther penetration and when coupled with
direct sur ace contact could allow or vessel damage
and or the argon gas to be ushed directly into the
venous system.
4. E. T e cautions o the manu acturer include:
1. Never place the electrode tip less than several
millimeters rom the surgical site.

2. Limit argon ow settings to lowest level that pro-
vides the desired clinical e ect.
3. Hold the tip o the electrode at an oblique angle.
4. Move the hand piece away rom the tissue a er
each activation.
5. Flush abdominal cavity with CO 2 between
extended activation periods o ABC.
6. Always leave one instrument cannula open to
the atmosphere.
Another recommended tip is the use o a venting
port at all times when operating laparoscopically and
using surgical energy. T is will allow gas to escape
but maintain a pneumoperitoneum.
5. C. In conjunction with appropriate cardiac resus-
citation according to ACLS guidelines i indicated,
the treatment o a patient suspected o having a CO2
or any gas embolism should include immediate dis-
continuation o CO2 insuf ation. T e patient should
be placed in Durants position (le lateral decubitus
with steep head down). T is allows the gas to rise into
the apex o the right heart, preventing entry into the
pulmonary artery and keeping it there until it slowly
absorbs. Use o nitrous oxide inhalant should be dis-
continued to allow or hyperventilation with 100%
oxygen to increase clearance o CO2 or any other
gas and to relieve hypoxemia. Volume expansion
with bolus crystalloid may reduce urther gas entry
by elevating CVP. And lastly, placement o a central
venous catheter or attempted aspiration o the gas
rom the right heart may also be per ormed. While a
transesophageal echo ( EE) may be diagnostic in the
event o a venous gas embolism, it is not a priority in
the unstable patient with suspected gas embolism.
C H AP TER 4 ARG O N G AS EM BO LI S M 15
BIBLIOGRAPHY
Cornejo A, Liao L, Kenneth W. Argon gas embolism with
the use o argon beam coagulation during open hepatic
resection. 2009;22(2). Available rom http://ispub.com/
IJS/22/2/7972. T e Internet Journal o Surgery Web site.
Croce E, Azzola M, Russo R, Golia M, Angelini S, Olmi S.
Laparoscopic liver tumour resection with the argon beam.
Endosc Surg Allied echnol. 1994;2(34):1868.
Farin G and Grund KE. echnology o argon plasma coagu-
lation with particular regard to endoscopic applications.
Endosc Surg Allied echnol. 1994;2:717.
Feldman L, Fuchshuber P, and Jones DB. T e SAGES Manual
on the Fundamental Use of Surgical Energy. Berlin, Ger-
many: Springer-Verlag; 2012.
Kono M, Yahagi N, Kitahara M, Fujiwara Y, Sha M, Ohmura A.
Cardiac arrest associated with use o an argon beam coag-
ulator during laparoscopic cholecystectomy. Br J Anaesth.
2001;87(4):6446.
Park EY, Kwon JY, Kim KJ. Carbon dioxide embolism during
laparoscopic surgery. Yonsei Med J. 2012;53:45966.
Ikegami , Shimada M, Imura S, et al. Argon gas embolism
in the application o laparoscopic microwave coagulation
therapy. J Hepatobiliary Pancreat Surg. 2009;16(3):3948.
Economic Cycle Research Institute (ECRI). Fatal gas embo-
lism caused by overpressurization during laparoscopic use
o argon enhanced coagulation. Health Devices. 1994 Jun;
23(6):2579.
Mann C, Boccara G, Grevy V, Navarro F, Fabre JM, Colson P.
Argon pneumoperitoneum is more dangerous than CO2
pneumoperitoneum during venous gas embolism. Anesth
Analg. 1997;85:136771.
Min SK, Kim JH, Lee SY. Carbon dioxide and argon gas embo-
lism during laparoscopic hepatic resection. Acta Anaesthe-
siol Scand. 2007;51(7):94953.
Reddy C, Majid A, Michaud G, Feller-Kopman D, Eberhardt
R, Herth F, et al. Gas embolism ollowing bronchoscopic
argon plasma coagulation: a case series. Chest. 2008; 134(5):
10669.
Veyckemans F, Michel I. Venous gas embolism rom an argon
coagulator. Anesthesiology. 1996;85(2):4434.
This page intentionally left blank
Adva nc es in La pa r o sc o py
Robert B. Lim
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 5
FLSAortic rocar Per oration

Megan Bowen

A 32-year-old woman, with a body mass index o 3. Injury to a major vessel a er trocar placement is
30 kg/m 2, was admitted to the hospital with acute usually signif ed by?
appendicitis. She was consented or a laparoscopic A. Visible bleeding
appendectomy. She had a previous surgical history o B. Retroperitoneal hematoma
cesarean section. C. Bradycardia
Following the administration o general anesthesia, D. Hypoxia
a curvilinear in ra-umbilical skin incision was made.
Blunt dissection was carried down to the ascia and the 4. T e distance between the abdominal wall and the
ascia was elevated and incised. Entry into the perito- aortic bi urcation in normal weight women (BMI
neal cavity was con rmed visually and a Hasson trocar < 25 kg/m2) is?
was inserted into the peritoneal cavity. A. 1.5 cm
B. 2.4 cm
1. What is the sa est technique to gain access to the
C. 3.5 cm
peritoneum or laparoscopic surgery?
D. 0.4 cm
A. Open technique (Hasson)
B. Veress needle
C. Direct trocar technique
D. None o the above

2. Following insu ation, a 30 laparoscope was

inserted. Upon general laparoscopic examination
o the peritoneal cavity, it was apparent that a
retroperitoneal hematoma was orming. What is
the most commonly injured vessel during trocar
placement?
A. Iliac vein
B. In erior vena cava
C. Aorta
D. Lumbar veins
E. Superior mesenteric vessels
20 G EN ERAL S U RG ERY EXAM IN ATIO N AN D BO ARD REVI EW
ANSWERS
1. D. T ere have been many studies done comparing
the sa ety o the open technique to the closed and
direct entry techniques. T ere has been no obvi-
ous advantage o one technique over another. One
large meta-analysis showed an incidence o vascular
injury to be 0.44% in the closed cases compared to
0% in the open cases. Another large study compared
the Veress, open and direct trocar techniques, and
ound a rate o vascular injury o 0.04%, 0.01%, and
0% respectively.
2. A. Vascular injuries may involve retroperitoneal,
intraperitoneal or abdominal wall vessels. Rates o
major vascular injury during initial trocar entry are
between 0.05% and 0.5%. T e sites o injury rom
most common to least common are iliac vein, greater
omental vessels, in erior vena cava, aorta, pelvic
and superior mesenteric veins, and lumbar veins.
Injury to a major vessel is usually signi ed by visible
bleeding and hemodynamic instability. I an injury
is con rmed or highly suspected, especially in the
retroperitoneum, convert to an open procedure and
explore the area in question.
3. A. Vascular injury is usually diagnosed by direct view
o bleeding in the abdominal cavity. T e absence o
ree intraperitoneal blood caused by retroperitoneal
bleeding may delay the diagnosis, because blood is not
observed through the laparoscope. Clinical signs o
hemodynamic instability (tachycardia, hypotension),
shortly af er needle or trocar insertion, suggest a vas-
cular injury. High intraabdominal pressure secondary
to pneumoperitoneum is associated with a decrease
in venous return, which in turn, can reduce arterial
bleeding. Furthermore, a retroperitoneal hematoma
can decrease a vessel leak, restraining the bleeding.
Un ortunately, 15% to 50% o the vascular inju-
ries are not diagnosed at the time o injury. T is delay
has contributed to mortality rates o 3% to 30% or
vascular injuries.
4. D. A study by Hurd et al. (Obstet Gynecol. 1992;80(1):
4851) that ound that the distance between the
umbilicus and the aortic bi urcation was 0.4 cm in
normal weight women (BMI < 25 kg/m), 2.4 cm in
overweight patients (BMI 2530 kg/m) and 2.9 cm
in obese patients (BMI > 30 kg/m). Lif ing the abdom-
inal wall may improve sa ety by increasing the distance
between the abdominal wall and the viscera. Lif ing
the abdominal wall by placing towel clips within 2 cm
o the umbilicus has been shown to provide signi cant
elevation o the peritoneum (6.8 cm above the viscera)
that was maintained during insertion.
BIBLIOGRAPHY
Hurd WW, Bude RO, DeLancey JO, Pearl ML. T e relation-
ship o the umbilicus to the aortic bi urcation: implications
or laparoscopic technique. Obstet Gynecol. 1992;80(1):
4851.
Pemberton RJ, olley DA, van Velthoven RF. Prevention and
Management o Complications in Urological Laparoscopic
Port Site Placement. European Urology. 2006;50:95868.
Seidman DS, Nasserbakht F, Nezhat F, et al. Delayed recogni-
tion o iliac artery injury during laparoscopic surgery. Surg
Endosc. 1996;10:1099101.
Vilos GA, ernamian A, Dempter J, Laberge PY. Laparoscopic
Entry: A Review o echniques, echnologies, and Compli-
cations. J Obstet Gynaecol Can. 2007;29(5):433447.
Vilos GA, Vilos AG, Abu-Ra ea B, Hollett-Caines J, Nikkhah-
Abyaneh Z, Edris F. T ree simple steps during closed lapa-
roscopic entry may minimize major injuries. Surg Endosc.
2009;23:758764.
Wind J, Cremers J, van Berge Henegouwen M, Gouma D,
Jansen F, Bemelman W. Medical liability insurance claims
on entry-related complications in laparoscopy. Surg Endosc.
2007;21:20949.
 6
Advanced Laparoscopy
and NO ES
Mark A. Gromski and Kai Matthes
Ms. B is a 33 year-old emale presenting to a general sur-
gery clinic to be evaluated or a potential cholecystec-
tomy. She has a history o periodic symptomatic biliary
colic over the past nine months. Approximately 6 weeks
ago, she was evaluated in the local emergency depart-
ment or severe right upper quadrant pain. A right upper
quadrant ultrasound showed no evidence o cholecysti-
tis but did show multiple stones in the gallbladder. Her
pain subsided with pain medications and IV uids, and
she was discharged rom the emergency department
with outpatient general surgery ollow-up. Prior to this,
she had had two additional episodes o intermittent right
upper quadrant pain.
She is an otherwise healthy individual, only tak-
ing oral birth control medications and a multivitamin
daily. Her body mass index is 26 kg/m 2. She has had no
previous abdominal operations.
Her main concern is scarring that may result rom a
potential gallbladder operation, and she comes to you
to discuss this.
1. What is the most appropriate intervention to
recommend at this time?
A. Standard laparoscopic cholecystectomy by general
surgeon
B. Single-incision laparoscopic (SIL) cholecystectomy
by general surgeon with no experience in SIL
C. Re erral to specialty center or transvaginal
Natural Ori ce ranslumenal Endoscopic Surgery
(NO ES) cholecystectomy
D. Ursodiol 8 to 10 mg/kg/day (in 2 divided doses
daily)
2. T e SIL approach is more technically demanding
than standard multi-port laparoscopic surgeries,
and requires additional specialized training.
Which is the most relevant reason or the increased
technical di culty in SIL?
A. Loss o triangulation
B. Cramped external working space secondary to
close proximity o instruments causing ergo-
nomic di culty
C. Decreased eld o view
D. Reduced range o motion o instruments
3. A patient was re erred to a surgeon within the same
institution who is well-experienced in single incision
laparoscopic cholecystectomy. When discussing the
single incision approach with the patient, attention
should be brought to which potential complication
that may be seen more requently in single-
incision cholecystectomy compared to standard
multi-port cholecystectomy?
A. Signi cant bleeding complications
B. Post-operative herniation
C. Pain
D. Surgical site in ections
4. A patient with achalasia is expressing signif cant
concerns over cosmesis. Which developing min-
imally invasive technique is considered an acceptable
alternative to a multi-port laparoscopic Heller
myotomy?
A. Per-oral endoscopic myotomy (POEM)
B. Single-port laparoscopic Heller myotomy
C. Hand-assisted laparoscopic Heller myotomy
D. ransvaginal NO ES myotomy
22 G EN ERAL S U RG ERY EXAM I N ATIO N AN D BO ARD REVI EW
5. Which o the ollowing is true regarding NO ES?
A. Sa e access to the peritoneal cavity is generally
not di cult to accomplish.
B. E ective management o iatrogenic intraperito-
neal complications are easily recognized.
C. E ective training requirements are well estab-
lished.
D. Most new equipment have multitasking plat orms
to accomplish procedures.
ANSWERS
1. A. Multi-port laparoscopic is considered the gold
standard approach to cholecystectomy, compared
to open approach, given equivalent serious com-
plications, improved cosmesis, improved pain and
decreased length o stay. Particularly considering
the patients concerns regarding cosmesis, an open
approach would not be appropriate in this case.
Ursodiol does not exert an in uence on symp-
tomatic gallstones that is nearly as e cacious or
durable compared to cholecystectomy. Particularly
considering this patient is a very low risk surgical
candidate, cholecystectomy is the correct approach.
Although there have been a number o large
series published regarding intra-abdominal natural
ori ce transluminal endoscopic surgery procedures
(NO ES; the majority o which are transvaginal
cholecystectomy), NO ES procedures require highly
specialized training, specialized technology and
mastery o the exible endoscope. A rigorous rand-
omized controlled trial comparing NO ES cholecys-
tectomy to standard laparoscopic cholecystectomy is
underway and nearing completion (NC 01171027).
Furthermore, the vast majority o clinical NO ES
transvaginal cholecystectomy cases reported were
hybrid cases, with at least one laparoscopic port. In
the absence o rigorous comparative data regard-
ing NO ES cholecystectomy to the standard o care,
it would be premature to recommend this as the best
treatment option available.
Finally, there is a de nite learning curve to single
incision cholecystectomy. One particular study dem-
onstrated a learning curve o about 25 cases, with the
majority o major complications, including conversion
to standard or open cholecystectomy, to occur in the
rst 10 cases. Given this, despite the patients concerns
regarding cosmesis, the sa est and most appropriate
option presented would not be a single incision chol-
ecystectomy by a surgeon who had never per ormed
that procedure be ore, but a multi-port laparoscopic
cholecystectomy by a general surgeon.
2. B. Given the instrument ports in single-port lapa-
roscopy (SIL) surgery are in such close proximity
to each other, the surgeon must utilize laparoscopic
devices which are, in essence, operated in parallel,
causing di culty in triangulation and awkward oper-
ating postures. Curved instruments are commer-
cially available providing some limited triangulation.
T e close proximity o the laparoscopic instruments,
of en requiring a crossing o the devices, is consid-
ered the most challenging aspect o SIL in compari-
son to a multi-port approach. Furthermore, given
the camera can only be placed in one anatomical
position (umbilicus), it can create a decreased eld
o view compared to multi-port access. In the same
regard, given the instruments are relegated to a sin-
gle anatomical position, the range o motion o the
instruments can at times be compromised com-
pared to a multi-port approach, but these latter two
reasons are considered less signi cant and encoun-
tered less requently than the ergonomic di culties
o SIL.
It has been proposed that robotic single-incision
laparoscopic techniques may overcome the ergo-
nomic di culties o current SIL procedures.
3. B. A recent meta-analysis per ormed demonstrated
that there were no clinically signi cant di erences
in bleeding or pain between single incision and
standard multi-port cholecystectomy. Another meta-
analysis also demonstrated no di erence in surgical
site in ections. T ere are no high quality data demon-
strating that there is a comparative mortality di erence
with either procedure.
T ere is, however, a signi cant di erence in post-
operative incisional hernia, with more occurring in
the single incision group. T is should be explained
to the patient in the clinic, particularly i she is plan-
ning to become pregnant in the uture. T is increase
in post-operative hernia is likely secondary to the
length o the ascial incision required by whichever
single-incision plat orm is chosen. T e ascial incision
can be up to 7 cm with some devices.
Furthermore, there are data that the rate o pro-
cedural ailure is higher in the single incision group
(mainly relating to conversion to multi-port laparo-
scopic) and the time o procedure is longer in the
single incision group.
 C H AP TER 6 AD VAN C ED LAPARO S CO P Y AN D N O TES
Finally, relative to this patient, there are data that
single incision laparoscopic cholecystectomy ares
better on post-operative cosmesis scores than multi-
port cholecystectomies.
4. A. Multi-port laparoscopic Heller myotomy is the
current gold standard operative approach or the
treatment o achalasia. A single incision laparoscopic
approach has been described in the literature, but
only as single case reports. T e anatomical location
o the repair makes a single incision approach di -
cult, and this technique has not been widely adopted.
Peroral Endoscopic Myotomy (POEM) is an endo-
scopic surgical approach that was rst described less
than a decade ago, and has gained increasing atten-
tion and adoption by surgeons and gastrointestinal
endoscopists alike. T e procedure consists o endo-
scopically creating a submucosal tunnel in the distal
esophagus, ollowed by creating a complete myotomy,
then retraction o the endoscope and closure o the
submucosal tunnel with endoscopic clips. T ere are
no external scars involved in this procedure and it
does not require laparoscopic equipment or ports. A
recent comparative study o POEM and laparoscopic
Heller myotomy demonstrated equal resolution o
symptoms in both groups, equal esophageal acid
exposure in both groups and shorter hospitalization
or the POEM group. T e POEM procedure should
be per ormed in an experienced center by an expert
endoscopist.
T ere are no cases o transvaginal NO ES myot-
omy in the literature. T is would be a risky NO ES
procedure, given the extreme length o instruments
needed to per orm the myotomy with this approach.
T ere are also no reports o a hand-assisted laparo-
scopic approach.
5. A. Although all o the answer choices were initially
cited in the original White Paper on NO ES pub-
lished by Rattner et al. (Surg Endosc. 2006;20:185),
translumenal access (predominantly transvaginal
and transgastric in published clinical cases) has
developed su ciently over the past decade, includ-
ing primary transvaginal opening techniques and the
submucosal tunnel technique or transgastric access.
ranslumenal closure applications have increased
since the publication o the initial NO ES White
Paper, including ull thickness endoscopic clips (e.g.,
O SC clip by Ovesco) and endoscopic suturing
devices (e.g., Overstitch by Apollo Endosurgery).
23
T ere remain signi cant concerns regarding
adequate training or NO ES procedures. T ere are
questions regarding the appropriate composition o
teams (gastroenterologist versus surgeon versus both),
the amount o advanced exible endoscopy experi-
ence required, and the appropriate amount o ex-vivo
simulation and live animal training prior to human
attempts.
In addition, there is a 5% to 10% rate o compli-
cations cited in current NO ES registries. T ere is
concern that current endoscopic techniques may not
be able to adequately address intraperitoneal surgical
complications, and that the delay in transitioning to
a laparoscopic approach to de nitively manage com-
plications may result in poorer outcomes. Addition-
ally, i gastroenterologists are a part o the NO ES
team (as they may be more acile with advanced
exible endoscopy), they are likely to be less amiliar
with the intraperitoneal anatomy and may not as
easily recognize intraoperative complications.
Finally, a pure NO ES approach using a exible
endoscopic approach requires a single operator to
manage both the visualization and spatial position-
ing o the endoscopic tools concurrently, which can
be cumbersome and is di cult in a NO ES appli-
cation. A multitasking NO ES plat orm would be o
pro ound bene t to the operator.
BIBLIOGRAPHY
Bhayani NH, Kurian AA, Dunst CM, Sharata AM, Rieder E,
Swanstrom LL. A comparative study on comprehensive,
objective outcomes o laparoscopic Heller myotomy with
per-oral endoscopic myotomy (POEM) or achalasia. Ann
Surg. 2014;259(6):1098103.
Chukwumah C, Zorron R, Marks JM, Ponsky JL. Current
status o natural ori ce translumenal endoscopic surgery
(NO ES). Curr Probl Surg. 2010;47:63068.
Douard R, Gaudric M, Chaussade S, Couturier D, Houssin
D, Dousset B. Functional results af er laparoscopic Heller
myotomy or achalasia: A comparative study to open sur-
gery. Surgery. 2004;136:1624.
Feinberg EJ, Agaba E, Feinberg ML, Camacho D, Vemulapalli
P. Single-incision laparoscopic cholecystectomy learning
curve experience seen in a single institution. Surg Laparosc
Endosc Percutan Tech. 2012;22:1147.
Gill IS, Advincula AP, Aron M, et al. Consensus statement o
the consortium or laparoendoscopic single-site surgery.
Surg Endosc. 2010;24:7628.
Inoue H, Minami H, Kobayashi Y, et al. Peroral endoscopic
myotomy (POEM) or esophageal achalasia. Endoscopy.
2010;42:26571.
Johansson M, T une A, Nelvin L, Stiernstam M, Westman
B, Lundell L. Randomized clinical trial o open versus
24 G EN ERAL S U RG ERY EXAM I N ATIO N AN D BO ARD REVI EW
laparoscopic cholecystectomy in the treatment o acute
cholecystitis. Br J Surg. 2005;92:449.
Kobayashi M, Mizuno M, Sasaki A, Arisue A, Akiyama S,
Wakabayashi G. Single-port laparoscopic Heller myotomy
and Dor undoplication: initial experience with a new
approach or the treatment o pediatric achalasia. J Pediatr
Surg. 2011;46:22003.
Lee SH, Kim SJ, Lee H, et al. Human applications o submu-
cosal endoscopy under conscious sedation or pure natural
ori ce transluminal endoscopic surgery. Surg Endosc. 2013;
27:301620.
Lehmann KS, Ritz JP, Wibmer A, et al. T e German registry
or natural ori ce translumenal endoscopic surgery: report
o the rst 551 patients. Ann Surg. 2010;252:26370.
Liu L, Chiu PW, Reddy N, et al. Natural ori ce transluminal
endoscopic surgery (NO ES) or clinical management o
intra-abdominal diseases. Dig Endosc. 2013;25:56577.
Marks JM, Phillips MS, acchino R, et al. Single-incision lapa-
roscopic cholecystectomy is associated with improved cos-
mesis scoring at the cost o signi cantly higher hernia rates:
1-year results o a prospective randomized, multicenter, sin-
gle-blinded trial o traditional multiport laparoscopic chole-
cystectomy vs single-incision laparoscopic cholecystectomy.
J Am Coll Surg. 2013;216:103747; discussion 478.
Milas M, Devedija S, rkulja V. Single incision versus stan-
dard multiport laparoscopic cholecystectomy: Up-dated
systematic review and meta-analysis o randomized trials.
Surgeon. 2014;12(5):27189.
Mo d H, Emmermann A, Alm M, von Walden els HA, Felix-
muller C, Zornig C. Is the transvaginal route appropriate
or intra-abdominal NO ES procedures? Experience and
ollow-up o 222 cases. Surg Endosc. 2013;27:280712.
Montero PN, Acker CE, Heni ord B , Ste anidis D. Single inci-
sion laparoscopic surgery (SILS) is associated with poorer
per ormance and increased surgeon workload compared
with standard laparoscopy. Am Surg. 2011;77:737.
Myotomy (POEM) or Achalasia. Ann Surg. 2014;259:1098
103.
Pietrabissa A, Sbrana F, Morelli L, et al. Overcoming the chal-
lenges o single-incision cholecystectomy with robotic
single-site technology. Arch Surg. 2012;147:70914.
Song , Liao B, Liu J, Yin Y, Luo Q, Cheng N. Single-incision
versus conventional laparoscopic cholecystectomy: a sys-
tematic review o available data. Surg Laparosc Endosc
Percutan Tech. 2012;22:e1906.
Rattner D. Introduction to NO ES White Paper. Surg Endosc.
2006;20:185.
Soper NJ, Stockmann P , Dunnegan DL, Ashley SW. Lapa-
roscopic cholecystectomy. T e new gold standard? Arch
Surg. 1992;127:91721; discussion 213.
rastulli S, Cirocchi R, Desiderio J, et al. Systematic review
and meta-analysis o randomized clinical trials comparing
single-incision versus conventional laparoscopic cholecys-
tectomy. Br J Surg. 2013;100:191208.
Venneman NG, Besselink MG, Keulemans YC, et al. Ursode-
oxycholic acid exerts no bene cial e ect in patients with
symptomatic gallstones awaiting cholecystectomy. Hepa-
tology. 2006;43:127683.
Wood SG, Panait L, Du y AJ, Bell RL, Roberts KE. Compli-
cations o transvaginal natural ori ce transluminal endo-
scopic surgery: a series o 102 patients. Ann Surg. 2014;259:
7449.
Yamada H, Yano . Single incision laparoscopic approach or
esophageal achalasia: A case report. Int J Surg Case Rep.
2013;4:14.
Yano F, Omura N, suboi K, et al. Single-incision laparoscopic
Heller myotomy and Dor undoplication or achalasia:
report o a case. Surg Today. 2012;42:299302.
Zorron R, Palanivelu C, Galvao Neto MP, et al. International
multicenter trial on clinical natural ori ce surgery
NO ES IM N study: preliminary results o 362 patients.
Surg Innov. 2010;17:14258.
 7
Robotic-Assisted Surgery
Brenda Schmidt and Gordon Wisbach
A 65-year-old man with a medical history o hyperten-
sion presents to the emergency room complaining o
rectal bleeding or 3 months. On physical exam, a rectal
mass and scant gross blood is discovered during a digi-
tal rectal exam. A proctoscopic evaluation localizes the
mass in the anterior rectum only 4 cm rom the dentate
line. A colonoscopy does not reveal any concomitant
lesions and a biopsy o the lesion con rms the mass
is adenocarcinoma. On endoscopic ultrasound, the
mass extends through the muscularis propria with one
abnormal lymph node. T ere is no involvement with
the sphincter muscles. His workup includes a C o the
abdomen and pelvis, with no signs o metastasis. He
completes neoadjuvant chemotherapy and returns to
clinic to discuss surgical treatment. Based on the loca-
tion o the tumor you recommend a robotic-assisted
laparoscopic anterior resection with a diverting loop
ileostomy.
1. Which o the ollowing is true regarding the
di erences between robotic and laparoscopic
resection o rectal cancer?
A. Improved oncologic resection lymph node sam-
pling and margin resections
B. Decreased incidence o bladder and erectile dys-
unction in men undergoing robotic-assisted
low anterior resection
C. T e robotic approach has decreased conversion
rates compared to laparoscopic.
D. T e increased cost o the robotic approach is o
set by the signi cantly decreased hospital length
o stay and complication rate.
2. O the ollowing surgeries, which has been shown
to benef t rom the robotic approach?
A. Cholecystectomy
B. Nissen undoplication
C. Prostatectomy
D. Adrenalectomy
E. Pancreatectomy
3. Which o the ollowing patients would most likely
benef t rom a robotic-assisted versus laparoscopic
surgery or colorectal cancer?
A. 75 year old admitted with a lower gastrointesti-
nal bleed, ound to have a bleeding cecal tumor
on colonoscopy
B. 60-year-old man with a low rectal cancer that is
abutting the prostate on endoscopic ultrasound
C. 64-year-old man with no signi cant medical
history with a descending colon mass
D. 55-year-old man admitted with obstipation
ound to have an obstructing sigmoid tumor
4. O the ollowing, which is considered to be one o
the advantages o robotic surgery?
A. Decreased overall cost
B. Motion scaling, which increases the light in
di icult to reach places
C. Improved ergonomics or the operating surgeon,
avoiding atigue and potential disability
D. T e ability to per orm multi-quadrant procedures
with ease
E. Endowrist technology, which allows better tac-
tile sensation
26 G EN ERAL S U RG ERY EXAM I N ATIO N AN D BO ARD REVI EW
5. Which o the ollowing is true regarding the
training required to per orm robotic-assisted
laparoscopic surgery?
A. As part o the learning curve or robotic-assisted
laparoscopic colorectal surgery, surgical e ciency
is best determined by operative time.
B. T e learning curve or robotic-assisted laparo-
scopic colorectal surgery is well de ned.
C. Simulation or robotic surgery is undeveloped,
and, there ore, not use ul in honing these skills.
D. T ere are no regulated, standardized training
programs or surgeons interested in per orming
robotic-assisted laparoscopic surgery.
ANSWERS
1. C. T e literature that analyzes robotic-assisted low
anterior and abdominoperineal resections, demon-
strates a lower conversion rate to open laparotomy as
the most signi cant advantage. A systematic review
and meta-analysis in 2011 suggested that the conver-
sion rate to open surgery in the robotic group was
signi cantly lower than that with laparoscopic sur-
gery. Another meta-analysis recently con rmed these
ndings by reporting a trend toward lower conver-
sion rates in the robotic surgery study arm. However,
there was no signi cant advantage o the robotic
approach in regards to the operative time, blood
loss, length o stay, and complications. T e potential
advantages o robotic surgery include a more accu-
rate pelvic dissection and, there ore, a decrease in
nerve injury in men resulting in decreased bladder
and erectile dys unction. However, these advantages
have not been well elucidated in the literature. Some
small studies have shown that there may be an earlier
return o unction in the robotic group but the inci-
dence o genitourinary dys unction appears to be the
same in either approach.
2. C. Although the types o surgeries per ormed with
robotic-assisted laparoscopy have greatly increased
over the last several years, there is still debate regard-
ing the bene t o robotic surgery. Although the advan-
tages o robotic-assisted laparoscopic prostatectomy
(RALP) are still debated, there is an increasing amount
o literature about this procedure. RALP has become
one o the most common robotic-assisted surgeries,
which accounted or 67% o all prostatectomies per-
ormed in 2009. T is demonstrates the pre erence o
surgeons to use robotics in a small space such as the
pelvis. Despite the ongoing debate, some have shown
a cost-e ectiveness o robotic-assisted prostatectomy
in high volume centers i over 150 surgeries are per-
ormed per year.
3. B. Robotic-assisted laparoscopic surgery is rarely
applied to emergent operations. As well, a laparo-
scopic approach is rarely pre erred in an urgent
colorectal operation including obstipation due to
an obstructing colon cancer. A randomized trial o
robotic-assisted versus laparoscopic colectomy or
right colon cancer showed hospital stay, surgical
complications, postoperative pain score, resection
margin clearance and number o lymph nodes har-
vested were similar in both groups, but the costs asso-
ciated with the robotic-assisted right colectomy were
higher. A nationwide analysis o robotic colorectal
surgery revealed anterior resections or rectal cancers
were the most common robotic assisted colorectal
surgery per ormed in the United States, accounting
or 40% o all robotic cases. A larger percentage o all
rectal cancers are being per ormed robotically com-
pared to colon resections, with a tendency toward
higher use o robotic-assisted techniques in males
undergoing anterior resection or rectal cancer. T is
study suggests that robotic assistance may be o no
added bene t in routine colon resections, but selec-
tive application in complex rectal cancer procedures
may prove to have long-term bene ts. O the choices
listed, the patient with the low rectal cancer abutting
the prostate is most likely to bene t rom robotic-
assisted surgery.
4. C. T ere are many advantages o robotic-assisted
laparoscopic surgery including: three-dimensional
high de nition vision; visual magni cation up to
15 times normal; motion scaling that will eliminate
a natural hand tremor as motions are deampli ed
up to a scale o 5 to 1; improved ergonomics or
the operating surgeon; and EndoWrist technology,
which allows the instrument to imitate normal wrist
and elbow motions. However, there are many dis-
advantages including: increased operative time and
cost, the loss o tactile sensation, an evolving learn-
ing curve and di culty when operating in multiple
quadrants o the abdomen. T is latter challenge is
a particular problem is highlighted during mobili-
zation o the splenic exure in the lef upper quad-
rant during a rectal resection. T is can be solved by
per orming a hybrid procedure, in which the splenic

exure is initially mobilized laparoscopically and the
rest is completed robotically.
5. D. Operative time is an inadequate surrogate to
determine learning curve or robotic surgery or
many reasons; most importantly shorter operative
times are not re ected in patient outcomes. A sys-
tematic review o trials examining learning curve in
laparoscopic and robotic-assisted colorectal surgery
suggests that using operative time is too simplistic
and the authors conclude that a shif toward a mul-
tidimensional assessment, such as a cumulative sum
(CUSUM) model, which assesses trends in surgical
outcomes, should be encouraged. Because learning
curve has been studied with multiple ways with di -
ering numbers o parameters, the learning curve is
not well de ned. Simulation or robotic surgery is
available and shown to be use ul in attaining com-
petency prior to per orming surgeries on patients.
For instance, an inexpensive and synthetic pelvic
training model has been developed to teach the
complex skills needed or success ul completion o
robotic rectal dissection. Surgeons are not necessar-
ily required to complete a competency based training
program prior to integrating robotic-assisted surgery
into their practice. A systematic review has demon-
strated that there are many di erent types o training
programs described, and provides guidelines or the
development o a structured training program.
BIBLIOGRAPHY
Barrie J, Jayne DG, Wright J, et al. Attaining surgical compe-
tency and its implications in surgical clinical trial design:
A systematic review o the learning curve in laparoscopic
and robot-assisted laparoscopic colorectal cancer surgery.
Annals of Surgical Oncology. 2013;21(3):82940.
Close A, Robertson C, Rushton S, et al. Comparative cost-
e ectiveness o robot-assisted and standard laparoscopic
prostatectomy as alternatives to open radical prostatectomy
or treatment o men with localized prostate cancer: a
C H AP TER 7 RO BO TI C - AS S I S TED S U RG ERY 27
health technology assessment rom the perspective o
the UK National Health Service. European Urology. 2013;
64(3):3619.
DAnnibale A, Pernazza G, Monsellato I, et al. otal mesorec-
tal excision: a comparison o oncological and unctional
outcomes between robotic and laparoscopic surgery or
rectal cancer. Surgical Endoscopy. 2013;27(6):188795.
Halabi WJ, Kang CY, Ja ari MD, et al. Robotic-assisted
colorectal surgery in the United States: a nationwide anal-
ysis o trends and outcomes. World Journal of Surgery;
2013;37(12):278290.
Kim J, Kim N, Lee K, et al. A comparative study o voiding
and sexual unction af er total mesorectal excision with
autonomic nerve preservation or rectal cancer: laparo-
scopic versus robotic surgery. Annals of Surgical Oncology.
2012;19(8):248593.
Kwon Y, Park S. Current choices in robotic surgery: Whether
to increase use. JAMA Surgery. 2014;149(7):627628.
Lin S, Jiang H, Chen Z, et al. Meta-analysis o robotic and
laparoscopic surgery or treatment o rectal cancer. World
Journal of Gastroenterology. 2011;17(47):521420.
Lowrance W, Elkin EB, Jacks LM, et al. Contemporary open
and robotic radical prostatectomy practice patterns among
urologists in the United States. T e Journal of Urology.
2012;187(6):208793.
Marecik SJ, Prasad LM, Park JJ, et al. A li elike patient simula-
tor or teaching robotic colorectal surgery: how to acquire
skills or robotic rectal dissection. Surgical Endoscopy. 2008;
22(8):187681.
Park JS, Choi GS, Park SY, et al. Randomized clinical trial o
robot-assisted versus standard laparoscopic right colec-
tomy. British Journal of Surgery. 2012;99(9):121926.
Parra-Davila E, Ramamoorthy S. Lap colectomy and robotics
or colon cancer. Surgical Oncology Clinics of North America.
2013;22(1):14351.
Ramamoorthy S, Obias V. Unique complications o robotic
colorectal surgery. Surgical Clinics of North America. 2013;
93(1):27386.
Schreuder HW, Wolswijk R, Zweemer RP, et al. raining
and learning robotic surgery, time or a more structured
approach: a systematic review. BJOG: An International Jour-
nal of Obstetrics and Gynaecology. 2012;119(2):13749.
rastulli S, Farinella E, Cirocchi R, et al. Robotic resection
compared with laparoscopic rectal resection or cancer:
systematic review and meta-analysis o short-term out-
come. Colorectal Disease. 2012;14.4:e134e156.
 8
Advanced LaparoscopySingle
Incision and roubleshooting
Robotic Surgery
Jigesh A. Shah and Omar Yuse Kudsi
You are asked to start a Minimally Invasive Surgical
(MIS) program at a new community hospital. T e chie
o sta has asked you to evaluate all the new minimally
invasive techniques and equipment, speci cally with
regards to patient sa ety, so that the hospital can pur-
chase the proper equipment or your program.
1. With regards to CO2 insuf ation in laparoscopic
surgery, which o the ollowing statements is true?
A. Reports estimate that an average laparoscopic
colectomy requires approximately 200 to 280
liters o carbon dioxide.
B. Insu ation lters composed o mesh with 0.1-
to 0.3-micron pores have been developed to
exclude the possibility o peritoneal contamina-
tion or disease transmission through the ow o
intra-peritoneal uid or particulate matter rom
the patient to the insu ator and then to the next
patient.
C. Several randomized controlled trials have dem-
onstrated a clinical bene t as well as a decrease
in lens ogging with the use o warmed and
humidi ed air.
D. ouching the laparoscope tip on viscera is a
maneuver that is commonly used in laparoscopic
surgery. However, this should be per ormed cau-
tiously as the laparoscope tip temperature can
commonly exceed 200F.
E. I the surgeon experiences di culty with pneu-
moperitoneum and inadequate relaxation o the
abdominal wall, a discussion with the anesthe-
sia team regarding consideration or additional
sedation or paralysis is not appropriate.
2. Regarding sa e use o energy devices in laparoscopic
surgery, such as monopolar instruments, which o
the ollowing is true?
A. T ermal injury cannot occur rom another
instrument i the electrically active instrument is
not touching it.
B. Disruptions in the insulation o an active instru-
ment may discharge energy to surrounding
structures or tissues leading to inadvertent
thermal injury.
C. Using monopolar devices on the so-called coag-
ulation mode creates less lateral energy spread
than the so-called cut mode.
D. Capacitive coupling cannot occur when a non-
conductor separates two conductors.
E. I the active electrode o a robotic instrument is
inserted through a non-metal trocar, the non-
metal trocar acts can unction as a capacitor,
causing potential injury.
3. With regards to robotic-assisted laparoscopic
surgery, which o the ollowing is correct?
A. T e current robotic surgery system has our
degrees o reedom with its instruments.
B. T e current robotic surgery system has a orded
the surgeon the ability to per orm laparoscopic
surgery with ull control o up to two surgical
instruments and the camera.
C. Potential advantages o the robotic surgery system
include tremor reduction, 3-D visualization, and
increased wrist action at the surgical site com-
pared with traditional laparoscopic instruments.
C H AP TER 8 Ad v An C Ed LAPARo s Co P y s i n g LE i n C i s i o n An d TRo u b LEs H o o Ti n g Ro b o Ti C s u Rg ERy
D. Industry representatives can be present to ensure
that the equipment is unctional, and are trained
to in uence surgical decision.
E. I needed, intra-operative cholangiogram is not
possible during a robotic-assisted laparoscopic
cholecystectomy.
4. While per orming robotic-assisted or traditional
laparoscopic surgery, which o the ollowing is
true regarding management o an intra-operative
complication?
A. While per orming a robotic-assisted Nissen un-
doplication, the surgeon encounters an isolated
iatrogenic distal esophageal per oration. T e
next step would include primary single-layer
repair without the planned undoplication.
B. While per orming a laparoscopic single-site
Nissen undoplication, the surgeon accidently
entered the pleural cavity. T e appropriate next
step would be immediate placement o a chest
tube and discontinuation o the procedure.
C. During a robotic-assisted laparoscopic inci-
sional hernia repair, the surgeon encounters an
enterotomy while per orming enterolysis on the
anterior abdominal wall. T e next step in man-
agement should include primary repair and
mesh placement i the spillage is controlled and
considered minimal.
D. Crepitus observed in the chest or the neck dur-
ing robotic-assisted or laparoscopic Nissen un-
doplication is a potential side e ect and will
most likely improve without any intervention.
E. Af er completing a di cult single-site laparo-
scopic bilateral inguinal hernia repair, the sur-
geon notices that the insu ation pressure was
set at 40 mm Hg during the case. T e next step
includes explaining the technical error to the
patient in the recovery room and scheduling a
ollow-up in the o ce one week later.
ANSWERS
1. D. o maintain pneumoperitoneum throughout a case,
a signi cant amount o CO2 is requently required.
T e duties o the surgical team include: monitoring
the intra-abdominal pressure during the case, identi y-
ing the amount o CO2 remaining prior to the start o
the surgical procedure and having a replacement tank
in reach i needed, especially or long or di cult cases.
One report estimated that an average laparoscopic
29
colectomy requires approximately 110 to 180 L o car-
bon dioxide. T e surgeon should be aware o that act,
making sure to check CO2 pressure in the tank prior
to start the surgery and clari y that a replacement tank
is available, i needed.
T e possibility o peritoneal contamination or
disease transmission through the ow o intra-
peritoneal uid or particulate matter rom the patient
to the insu ator (and then to the next patient) has
been a concern since the early days o laparoscopy.
o address this concern, insu ation lters composed
o mesh with 0.1 to 0.3-micron pores have been
developed, which limit, but do not exclude the pos-
sibility o disease transmission.
Warmed, humidi ed gas is sent directly rom the
insu ator (or gas is sent rom the insu ator through
a warming and humidi cation system prior to
patient delivery) in order to enter the peritoneal cav-
ity at body temperature. In addition to the theoreti-
cal bene t o improved visualization attributable to
condensation prevention, there is some evidence that
warm, humidi ed gas can also reduce hypothermia
and pain, however, several randomized controlled
trials have ailed to show either a clinical bene t or
a decrease in lens ogging with the use o warmed,
humidi ed air.
Wiping the laparoscope tip on the viscera, of en
the liver or small bowel, is another maneuver that is
commonly used and is of en e ective. However, this
should be per ormed with extreme caution as the
laparoscope tip temperature can of en exceed 200F.
2. B. Current concepts in electrosurgery are based on
the idea o monopolar and bipolar instrumentation.
Monopolar instruments are an active electrode,
to deliver concentrated energy, and require a sec-
ond, dispersive electrode, placed on the patient to
complete the circuit. Of en, the size o the dispersive
electrode is much larger than the active electrode to
decrease the delivered energy and prevent thermal
injury. Bipolar instruments in comparison contain
both the active and dispersive electrodes in a sin-
gle hand instrument, thereby delivering concentrated
and ocused energy to a particular location. Addition-
ally, two modes o energy delivery are used in mod-
ern day electrosurgical units. T e cut mode delivers
a low-voltage, continuous output, while the coagula-
tion mode delivers a high-voltage, interrupted out-
put. T ese modes re ect the energy wave orms and
not their designated labels. For urther in ormation,
30 g En ERAL s u Rg ERy EXAM i n ATi o n An d b o ARd REv i EW
please re er to the SAGES FUSE (Fundamental
Use o Surgical Energy) Handbook.
Metallic trocars are of en utilized in both laparo-
scopic and robotic surgery or cost reduction with
current robotic surgery instrumentation requiring
the use o metal trocars. It is important to under-
stand the associated possible injuries i these trocars
are placed beyond the suggested ascial point and/
or come in touch with intra-abdominal organs. With
direct coupling, the capacitor generates an elec-
trostatic eld between the active electrode and the
metal trocar, and as electricity passes through the
active electrode, the electrostatic eld can trans er
energy to the metal trocar, which will then discharge
the energy in the orm o heat, leading to burns o
the skin and abdominal wall, which is common in
robotic-assisted surgery per ormed using metal tro-
cars. T e use o non-conductive plastic trocars can
avoid this phenomenon.
T e use o monopolar instruments possess an addi-
tional risk, known as capacitive coupling, where by
electrical energy is stored in a capacitor (instrument)
and then discharged when the circuit is completed.
Of en, injuries o this type occur with accidental
contact o a recently used instrument, which retains
stored energy, with nearby tissue causing accidental
thermal injuries. T us, whenever monopolar electro-
cautery is being utilized, it is important to ensure that
there is a sa e distance between the active instrument
and all other metallic objects.
3. C. Robotic surgery has up to 7 degrees o reedom
with its instruments and provides the ability to per-
orm laparoscopic surgery with ull control o up to
three di erent surgical instruments as well as the
camera by a single operator. T e potential advantages
o robotic-assisted laparoscopic surgery include
tremor reduction, 3-D visualization, and increased
wrist action at the surgical site.
Intra-operative cholangiogram is possible during
robotic cholecystectomy and i needed any o the
robotic arms can be undocked and moved away or
cholangiography and/or placement o assistant ports.
Application o surgical sa ety standards to robotic
surgery include credentialing, mentorship, knowledge
o laparoscopic physiology, case selection appropri-
ateness to skills level, conversion to an open proce-
dure when needed, and industry representatives can
be present to ensure that the equipment is unctional,
however they are not trained or credentialed to in u-
ence any surgical decision making.
4. D. Given that sa ely per orming minimally invasive
surgery requires an advanced set o skills, the Ameri-
can Board o Surgery adapted the Fundamentals o
Laparoscopic Surgery (FLS) course prior to being eli-
gible sit or board examination. Surgeons per orm-
ing minimally invasive surgery should be prepared
to deal with potential complications that could arise,
as well as be com ortable with the open technique, i
needed.
Possible complications o both robotic-assisted
and laparoscopic Nissen undoplication include
entering into the pleural cavity, which is of en man-
aged by decreasing the insu ation pressure and
good communication with the anesthesiologist. As
long as the patient remains stable and there is no
di culty in ventilation the procedure can continue
as planned and post-operative chest X-rays can be
obtained to con rm the resolution o CO2. Chest
tube placement is not immediately required, unless
the patient becomes symptomatic.
Iatrogenic injury to the esophagus is a potential
complication during Nissen undoplication and can
be avoided by handling the esophagus with umbilical
tape (the no-touch technique). It is recommended to
repair an iatrogenic injury with a primary, two layers
closure with the planned portion o the Nissen wrap
covering the primary repair site. An enterotomy is a
contraindication or synthetic mesh placement irre-
spective to the amount o spillage or contamination
and should not be per ormed.
Crepitus is of en seen af er mediastinal dissec-
tion and usually resolves spontaneously without any
additional treatment. Monitoring insu ation pres-
sures during surgery is important throughout the
duration o a case since high insu ation pressures
can lead to serious complications such as di culty
with extubation due to CO2 retention and end-organ
ischemia ( or example, acute renal ailure). For these
reasons, patients that undergo procedures with high
insu ation pressures should be admitted to the hos-
pital or observation and closely ollowed clinically.
BIBLIOGRAPHY
Brunt LM. Fundamentals o electrosurgery part II: T ermal
injury mechanisms and prevention. In: Feldman LS,
Fuchshuber PR, Jones DB, eds. T e SAGES Manual on the
C H AP TER 8 Ad v An C Ed LAPARo s Co P y s i n g LE i n C i s i o n An d TRo u b LEs H o o Ti n g Ro b o Ti C s u Rg ERy
Fundamental Use of Surgery Energy (FUSE); New York, NY:
Springer-Verlag; 2012;6179.
Diamantis , Kontos M, Arvelakis A, et al. Comparison o
monopolar electrocoagulation, bipolar electrocoagulation,
Ultracision, and Ligasure. Surg oday. 2006;36:90813.
Farley DR, Greenlee SM, Larson DR, Harrington JR. Double-
blind, prospective, randomized study o warmed, humidi-
ed carbon dioxide insu ation vs standard carbon dioxide
or patients undergoing laparoscopic cholecystectomy.
Arch Surg. 2004;139:73943; discussion 434.
Funk LM, Greenberg JA. Minimally invasive surgery: Equip-
ment and troubleshooting. In: Souba WW, Fink MD,
Jurkovich GJ, Pearce WH, Pemberton JH, Soper NJ, eds.
ACS Surgery: Principles and Practice. New York, NY: Marcel
Dekker; 2011;(21):110.
Larson JA, Johnson MH, Bhayani SB. Application o surgical
sa ety standards to robotic surgery: Five principles o ethics
31
or nonmale icence. J Am Coll Surg. 2014; Feb; 218(2):
2903.
Randles VC. T e art and science o monopolar electrosurgery.
In: Feldman LS, Fuchshuber PR, Jones DB, eds. T e SAGES
Manual on the Fundamental Use of Surgery Energy (FUSE);
New York, NY: Springer-Verlag; 2012;8191.
Sammour , Kahokehr A, Hayes J, et al. Warming and humidi-
cation o insu ation carbon dioxide in laparoscopic
colonic surgery: a double-blinded randomized controlled
trial. Ann Surg. 2010;251:102433.
rastulli S, Cirocchi R, Desiderio J, et al. Robotic versus lapa-
roscopic approach in colonic resections or cancer and
benign disease: Systematic review and meta-analysis. PLoS
One. 2015;10(7):126.
yler JA, Fox JP, Desai MM, et al. Outcomes and costs associ-
ated with robotic colectomy in the minimally invasive era.
Dis Colon Rectum. 2013; Apr; 56(4):45866.
This page intentionally left blank
Et h ic a l a nd Leg a l Issues
Robert B. Lim
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 9
Ethics/Legal Issues
Decision Making
S v A z r S w

A 37-year-old man and his 16-year-old daughter are
brought into the emergency department via ambulance
a er being involved in an automobile collision. T e man is
ully conscious and alert. He in orms the hospital sta that
both he and his daughter are Jehovahs Witnesses. Radio-
logical studies indicate that the man su ered a broken pel-
vis and his daughter is experiencing internal bleeding. It is
concluded that both individuals will need surgery.
B. Her ather still maintains legal right over her
because she is not o legal age. Make sure he is clear
o any added risks associated with her surgery i
he re uses any blood products or his daughter.
C. She is old enough to be considered a mature
minor. T ere ore her decision to re use blood
products must be respected.
D. Call risk management.

1. L b work m ow mo ob 3. T m m o p b oo
m o r o r by p m pro .W po b o q or
r r or b oo r o .H m o wor o o ?
o r v y b oo pro b o A. He would be ostracized by his mother.
r o .W x p yo m o? B. Be required to pay a $25,000 donation to expunge
A. Respect his wishes and proceed with bloodless his transgression.
surgery protocols. C. Lose the privilege o attending church services until
B. Begin searching or a nearby bloodless surgery church elders deemed him su ciently repentant.
center that is better equipped to handle his D. All o the above
situation.
C. Discuss his belie . ANSWERS
D. Call the Hospital Liaison to determine what are
your legal responsibilities. 1. C. alk to the patient privately in order to get a better
understanding o his personal belie s. T e Jehovahs
2. T m r o o o Witnesses (JW) religion is known or its re usal to
o o . A o po o v rb y allow blood trans usions. T e current JW position
o f rm r r o b oo pro . How v r includes unconditional re usal o whole blood, packed
r f b b oo r r red blood cells, white blood cells, platelets, and plasma.
r po k . W ppropr r po ? T is includes the autologous trans usion o their own
A. Use whatever means are necessary during sur- pre-deposited blood. However, many Witnesses accept
gery. T e patient is a legal minor and thus you intra-operative blood salvage so long as their blood
have the right under doctrine o parens patriae remains in circulation within the body. T ey may
to do so. also accept albumin, immune globulin, hemophilia
36 G EN ERAL S U RG ERY EXAM I N ATI O N AN D BO ARD REVI EW
preparations, sera, and even organ transplantation on
an individual decision. It is there ore vital that each
case be discussed and treated individually.
Witnesses cannot be treated appropriately without
exploring personal conviction and pre erence. It is impor-
tant that the physician discuss these matters in private.
T e patients autonomy to make medical decisions
can be greatly in uenced by amily members, riends,
and congregational members. Case reports have even
shown that patients have changed their earlier decision
to accept blood treatment a er being visited by hospital
liaison committee members. T ese members are o en
called upon by doctors in order to help determine indi-
vidual treatment. Due to their potential in uence, this
practice may have to be reconsidered.
2. D. Contact risk management i unsure. It is impor-
tant or medical pro essionals to be amiliar with
their particular states laws regarding minors con-
sent authority. Most states require parental consent
and do not permit mature minors to consent to gen-
eral medical care. However, parental rights are not
absolute. T ey have a responsibility to make deci-
sions that ensure the health and sa ety o their child.
Courts can exercise their power under the doctrine
o parens patriae to orce medical treatment when
parents put their childs health in jeopardy. T e case
o Prince v Massachusetts is o en cited because it
clearly mentions that parents have every right to die
or their religious belie but cannot make that same
decision or their children.
3. A. He would be ostracized by his mother. Muramoto
has sited Church literature that appears to teach that
JWs who come across conf dential medical in orma-
tion are obligated to bring that in ormation to the
attention o the church elders. Not only could there
be legal ramif cations or any healthcare worker
caught doing so, but there could be a resulting coer-
cive e ect in a JW patients decision making process.
A breach in conf dentiality could a ect a church
member in other serious ways.
In 1961 the JW began to en orce the policy o blood
re usal by dis ellowshipping, or expelling, un-repentant
members who will ully accept blood components that
are prohibited. T e Church conducted judicial proceed-
ings whenever members were suspected o receiving
blood products. T ese proceedings would ultimately
yield an involuntary con ession rom the patient
and result in his dis ellowshipping. Witnesses, which
included amily and riends, would then be instructed
to ostracize and shun the expelled individuals. T is
practice is used by the JW to serve as a deterrent or
anyone acting against its teachings. Dissidents within
the JW have voiced that the practice coerces and com-
promises autonomous decisions in medical care.
In June 2000, the church released a statement indi-
cating that there would be a procedural change in
which the congregation would no longer initiate the
action to revoke membership or a baptized member
who wil ully and without regret accepts blood trans-
usions. It would be le up to the individual to come
orth and divulge his own actions to the church. T e
person would then be labelled as disassociated
because he had will ully broken a core tenet o their
aith. T is too would subject the individual to being
ostracized. T e important di erence between these
two processes is that a JW member could now keep
quiet about receiving blood and avoid excommuni-
cation altogether. Maintaining patient conf dentiality
is there ore paramount.
BIBLIOGRAPHY
Coleman DL, Roso PM. T e legal authority o mature
minors to consent to general medical treatment. Pediatrics.
2013;131(4):78693. doi:10.1542/peds.20122470.
Mann MC, Votto J, Kambe J, McNamee MJ. Management o
the severely anemic patient who re uses trans usion: les-
sons learned during the care o a Jehovahs Witness. Annals
o internal medicine. 1992;117:10428.
Muramoto O. Bioethics o the re usal o blood by Jehovahs
Witnesses: Part 1. Should bioethical deliberation consider
dissidents views? J Med Ethics. 1998; 24(4): 22330. Avail-
able rom: http://www.pubmedcentral.nih.gov/articleren-
der. cgi?artid= 1377670&tool= pmcentrez&rendertype=
abstract. Accessed May 26, 2014.
Muramoto O. Bioethical aspects o the recent changes in the
policy o re usal o blood by Jehovahs witnesses. BMJ. 2001;
322(7277):379. Available rom: http://www.pubmed-
central.nih.gov/articlerender. cgi?artid= 1119307&tool=
pmcentrez&rendertype = abstract. Accessed May 26, 2014.
Muramoto O. Bioethics o the re usal o blood by Jehovahs
Witnesses: Part 3. A proposal for a dont-ask-dont-tell policy.
J Med Ethics. 1999;25:4638. doi:10.1136/jme.25.6.463.
Woolley S. Children o Jehovahs Witnesses and adolescent
Jehovahs Witnesses: What are their rights? Arch Dis Child.
2005;90:7159. doi:10.1136/adc.2004.067843.
 10
End o Li e Care
Jenny Lam and Shawn Tsuda
An 85-year-old emale presents to the hospital with
nausea, vomiting, abdominal pain, and distension or
the past two days. T e pain rapidly worsens over the
next hour and the patient is taken to the OR with the
diagnosis o mesenteric ischemia. T e patient has a past
medical history o coronary artery disease, COPD, and
osteoporosis. She currently lives in a nursing home and
is able to per orm activities o daily living with assis-
tance. Be ore taking the patient to the OR, you con rm
that the patient has no living will or durable power o
attorney, but does state that she wouldnt want to be a
vegetable on a machine. During the surgery the patient
is ound to have extensive necrotic bowel rom the
ligament o reitz to the transverse colon. T e patient
is closed without resection. A er surgery the patient
rapidly deteriorates and develops severe septic shock.
A discussion occurs with the patients amily about the
poor prognosis o this illness. T e patients daughter,
whom is the next o kin, states that she wants everything
to be done or her mother and threatens legal action i
her wishes are not granted.
1. What is the next appropriate step in managing this
patient?
A. ake the patient back to the OR to per orm a
subtotal colectomy as per the daughters wishes.
B. In orm the daughter that she has no decision
making capabilities and proceed with palliative
care.
C. Remove the patient rom nutritional support
and hydration.
D. Consult the hospitals ethics committee.
E. Continue to discuss options with the amily.
2. In regards to advance directives, which statement
is correct?
A. Advanced directives are not trans erable between
states.
B. Oral advance directives are legally valid.
C. A living will takes precedence over appointed
surrogate decision making.
D. Advance directives are always ollowed verbatim.
3. In regards to life-sustaining medical treatment,
which statement is correct?
A. T ere is no ethical di erence between withdraw-
ing and withholding treatments.
B. Risk management personnel must be consulted
be ore li e-sustaining medical treatment may be
terminated.
C. A patient has to be terminally ill or li e support
to be stopped.
D. It is permissive to withhold extraordinary care,
but not ordinary care.
E. It is illegal to provide palliative care to a termi-
nally ill patient i there is a possibility that this
may hasten the patients death.
ANSWERS
1. E. When making decisions about end o li e care it
is important or all involved parties to have a gen-
eral consensus about care. Emotions and psychologi-
cal strain can heavily in uence decision making, but
it is important to remind involved parties that the
most important decision making actor is what the
patient would have wanted. I the patient is no longer
38 G EN ERAL S U RG ERY EXAM I N ATIO N AN D BO ARD REVI EW
competent to make decisions, it is reasonable to
ascertain what they would have wanted rom previ-
ous comments about similar situations. Advanced
directives, living wills, or appointed surrogates
are commonly used to make decisions but in their
absence, in ormal advanced directives or next o kin
are implicated. In this case the patient has stated she
would not want any heroic li e-saving measures to
be taken. Oral advance directives are legally valid,
and should be documented in the patients medical
records. T e next o kin has rights to make decisions
about patient care as long as these decisions are con-
sistent with the patients autonomous wishes. Further
discussion with the amily may make this clear and
avoid unwanted court intervention.
2. B. Advance directives provide in ormation about a
patients wishes regarding their healthcare when they
are no longer competent to make decisions. Many
advance directives contain provisions allowing the
directive to be en orceable in whichever state they
are currently residing in. Even without such a provi-
sion oral in ormal advance directives made about
treatment pre erences are legally valid and are upheld
in court as a sworn testimony about statements the
patient made prior to their illness. Living wills o en
lack the speci c details to direct care in un oreseen
circumstances. A surrogate can be appointed to make
real-time decisions on behal o the patient remov-
ing the responsibility o a provider to attempt inter-
pretation a patients wishes. When a durable power
o attorney is appointed they become an extension
o the patient and may make decisions that con ict
with a written advance directive, so long as they
promote the best interest o the patient. Regardless
o the preparation a patient takes in preparing an
advanced directive, their wishes cannot always be
carried out. A recent study showed that a large por-
tion o patients that requested aggressive care did not
receive it as either such care was not an option or the
patient had appointed a surrogate that overrode the
previous pre erence.
3. A. T ere is no di erence between withdrawing and
withholding care, such that one action is not more
ethically sound then the other. It is not more uneth-
ical to stop li e sustaining therapy versus never hav-
ing started in the rst place. However, physicians
are less likely to withdraw care once it has been ini-
tiated.
Risk management personnel are consulted to
limit legal risk in regards to patient care. Some hos-
pital policies may require a consult be ore terminat-
ing li e-sustaining treatment, but there is no law that
indicates this as a prerequisite.
T ere is a very ne line that marks the distinction
between extraordinary care and ordinary care.
Extraordinary care or heroic measures are ones that
take over normal physiologic unction o the body in
end-organ ailure. Examples would include the use o
ventilators or pulmonary ailure or hemodialysis or
kidney ailure. Ordinary care helps the body sustain
itsel , with treatment such as IV uids, tube eeds, or
antibiotics. In a Supreme Court ruling in 1983, it was
ound that any treatment could be declined under
the Fourteenth Amendment o the U.S. Constitution,
be it extraordinary or ordinary, as long as this is in
the best interests in the patient and the burden o
medical care outweighs the bene ts.
T e principle o double e ect states that it is ethi-
cal to initiate a treatment that is intended to bene t
a patient even i the there is an unintended negative
consequence. T e bene t must be suf ciently substan-
tial to outweigh the risk. T e act must also directly
cause the bene t and not be intrinsically harm ul. An
example would be giving a patient high dose opiates
to relieve pain, but then unintentionally hastening the
patients demise by way o respiratory depression.
BIBLIOGRAPHY
Annas GJ: Nancy Cruzan and the right to die. N Engl J Med.
1990;323(10):6703.
Emanuel EJ. Palliative and End-o -Li e Care. In: Longo DL,
Fauci AS, Kasper DL, et al. Harrisons Principles of Inter-
nal Medicine. Eighteenth ed. New York, NY: McGraw-
Hill; 2012. Available rom http://www.accessmedicine
[accessmedicine].com
Hall DE, Angelos P, Dunn GP, et al. Ethics, Palliative Care, and
Care at the End o Li e. In: Brunicardi F, Andersen DK,
Billiar R, et al. Schwartzs Principles of Surgery. Ninth ed.
New York: McGraw-Hill; 2010. Available rom http://www.
accessmedicine[accessmedicine].com
Lo B. Surrogate Decision Making. In Lo B. Resolving Ethical
Dilemmas: A Guide For Clinicians. Fourth ed. Philadelphia,
Pennsylvania: Lippincott Williams & Wilkins: 2009;1016.
Meisel A, Synder L, Quill . Seven legal barriers to end-o -
li e care: Myths, realities, and grains o truth. JAMA. 2000;
284(19):2495501.
Pawlik M: Withholding and withdrawing li e-sustaining
treatment: A surgeons perspective. J Am Coll Surg. 2006;
202(6):9904.
Silveira M, Kim SYH, Langa KM: Advance directives and out-
comes o surrogate decision making be ore death. N Engl J
Med. 2010;362(13):121118.
Skin a nd So f t Tissue
Richard Smith
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 11
Skin Cancer
Jigesh A. Shah and Omar Yuse Kudsi
1. A 70-year-old male presents to your o ce with a
concerning 2 cm painless lump on his le hip that
he noticed over the last year, which is f rm and
dome-shaped. An excisional biopsy is per ormed,
demonstrating a Merkel cell carcinoma (MCC)
with negative margins. Regarding MCC, which o
the ollowing is true?
A. T e Merkel cell polyomavirus likely contributes
to the development o most Merkel cell carci-
noma.
B. A sentinel lymph node biopsy is required only
or tumors > 2 cm in size.
C. Risk actors or Merkel cell carcinoma include
having dark skin, a weakened immune system,
and overexposure to UV radiation.
D. Merkel cell dense-core granules stain positively
or the neuroendocrine marker neuron speci c
enolase.
E. Current recommendations or tumor excision
are with a 0.5-cm margin or tumors < 2 cm in
size and 2-cm margins or those > 2 cm in size.
2. A 50-year-old air skinned, blue-eyed male presents
to your o ce with a skin lesion on the pinna o
his right ear concerning or a melanoma. Biopsy
determines a superf cial spreading melanoma with
a depth o 1.1 mm. What is the next step in the
management o this patient?
A. Wide local excision and sentinel lymph node
biopsy
B. High dose inter eron alpha 2b is recommended
C. Radiation therapy
D. Excisional biopsy and a total parotidectomy
E. Complete surgical excision with a 0.5 cm nega-
tive margin
3. An 86-year-old emale presents to your o ce
with a new 1.8-cm raised pearly nodule with
sur ace telangiectasias on her cheek. Which o
the ollowing would be the best option in her
management?
A. Surgical excision with 1 cm margins
B. Cryotherapy
C. Mohs microsurgery
D. Radiation therapy
E. opical imiquimod
4. A 61-year-old male presents to your o ce with
a lesion on his lower lip. Biopsy conf rms a
squamous cell carcinoma, 2 cm in diameter. In
regards to squamous cell carcinoma (SCC), which
o the ollowing is true?
A. Squamous cell carcinoma o the lip most o en
presents on the upper lip.
B. Squamous cell carcinoma is the second most
common cutaneous cancer in patients who have
had a kidney transplant.
C. Actinic keratosis is not a risk actor or the devel-
opment o squamous cell carcinoma.
D. Lip de ects involving at least one-third o the lip
require regional aps such as an Abbe ap.
E. Margins or low risk squamous cell carcinoma
range rom 1.0 to 2.0 cm.
42 G EN ERAL S U RG ERY EXAM I N ATI O N AN D BO ARD REVI EW
5. A 79-year-old male presents with 2-cm scaly pink
lesion on his scalp that his primary care physician
has been ollowing or the last two years. Biopsy
conf rms the diagnosis o a basal cell carcinoma.
Which o the ollowing is correct in regards to
basal cell carcinoma?
A. Basal cell carcinoma is the second most common
orm o skin cancer, a er squamous cell carci-
noma.
B. Super cial basal cell carcinomas are scaly, pink
to red lesions requently con used with psoriasis
or other eczematous dermatoses.
C. Basal cell carcinomas commonly develop in
burn scars or chronic in ammatory wounds.
D. Surgical margins or low risk basal cell carcinoma
range rom 0.5 to 1.0 cm.
E. Mohs microsurgery cannot be considered an
option in the treatment o basal cell carcinomas.
ANSWERS
1. A. T e mainstay o therapy or patients newly diag-
nosed with primary MCC remains surgical. Current
recommendations are based on the clinical size o
the primary tumor and call or tumor excision with
1 cm margins or tumors that are 2 cm in size and
2 cm margins or those that are greater than 2 cm
in size. Radiotherapy has been used as monother-
apy or primary tumors with reported success, but
until more data become available, surgery remains
the mainstay o therapy or primary MCC tumors.
Furthermore, Feng et al. characterized a novel poly-
omavirus, the MCPyV, and suggested an association
between it and the pathogenesis o MCC. T is work
has sparked great interest in MCC and has opened a
new pathway in the study o viral tumorigenesis.
T e role o chemotherapy in the treatment o
MCC remains unclear. Since nearly one-third o
clinically node-negative patients harbor microscopic
nodal disease, sentinel lymph node biopsy (SLN) is
currently recommended or Merkel cell carcinoma at
the time o wide local excision. SLN biopsy has been
shown to be important in the staging and progno-
sis o MCC, and SLN status is included in the most
recent American Joint Committee on Cancer (AJCC)
staging guidelines. SLN biopsies should be examined
by both hematoxyin and eosin (H&E) and immu-
noperoxidase staining, including CK20. I sentinel
nodes are positive, completion lymph node dissec-
tion o the nodal basin ollowed by radiotherapy o the
basin is recommended. In cases where SLN positivity
is ound on immunostaining but not H&E staining
o the lymph node, radiotherapy without complete
lymph node dissection has been suggested as sole
regional therapy. Dark skin is not a risk actor, white
skin is. T e other two are risk actors.
2. A. umor thickness is critical or establishing the
prognosis in melanoma and regional metastases indi-
cates poor prognosis. Frozen sections have no role in
the diagnosis or treatment o melanoma. Once the
dermis in invaded the probability o regional or dis-
tant metastases increases substantially. Lymphoscin-
tigraphy and sentinel lymph node biopsy became the
primary method o identi ying nodal drainage pat-
terns replacing the prior suggested nodal drainage
based on location. ragus and anterior pinna lesions
were thought to metastasize to the parotid gland and
anterior cervical lymph nodes, whereas posterior
pinna lesions were thought to spread to the mastoid
bone and occipital and posterior cervical nodes. Com-
plete surgical excision with 1 to 2 cm margin is the
treatment o choice. Elective neck dissection is generally
not recommended or lesions less than 1 mm in thick-
ness, whereas lymphadenectomy may of er survival
advantage and better local control or lesions > 1 mm
in depth and positive sentinel lymph node biopsy (see
able 11-1). Inter eron alpha-2b is recommended or
patients with lymph node positive disease. Dif erent
types o melanoma are described in able 11-2.
Table 11-1 EXCISION MARGIN OF MELANOMAS
Depth o Suggestion
T Stage Invasion (mm) Margin (cm)
1 <1 1
2 12 1
3 2.014 2
4 >4 2
3. C. Basal cell carcinoma could be treated either surgi-
cal or medically. reatment options include wide local
excision, Mohs microsurgery with 4 mm margins,
curettage, and cryosurgery. T e standard treatment
or larger basal cell carcinoma is surgical excision with
cure rates greater than 99% or primary lesions; how-
ever or small lesions or lesions in areas such as the
ace, Mohs microsurgery is the pre erred treatment
option. Non-surgical treatments, typically reserved
or non-surgical candidates include radiotherapy,

Table 11-2 TYPES OF MELANOMA
Type Characteristics
Super cial Most common, associated with
spreading congenital nevi/dysplastic nevi.
Prominent radial growth
Nodular Prominent vertical growth, dark
pigmentation
Lentigo maligna Arise in sun exposed areas, occur at
dermalepidermal junction
Acral lentiginous Least common, arise on palmar,
plantar, mucosal, and subungual
regions. Common in dark-skinned
and Asian patients
topical and photodydnamic therapy. opical therapy
includes 5- uorouracil and imiquimod. Imiquimod,
a nonspeci c immune response modi er, has been
approved or the treatment o super cial basal cell
carcinoma smaller than 2 cm or ve times per week
or the duration o 6 weeks with clearance rate more
than 80%.
4. D. In immunosuppressed transplants patients, SCC
is the most common skin cancer and it tends to have
a more aggressive behavior. Lip carcinoma is the
most common oral cavity cancer, with a majority o
these lesions occuring on the lower lip. A majority o
patients with oral cavity carcinomas have a history
o either excessive alcohol intake or tobacco use. Lip
carcinoma most likely presents as an exophytic mass
and diagnosis is obtained by biopsy. Risk actors or
SCC include actinic keratosis, burn wound scars and
chronic in ammatory wounds. Large de ects that
involve up to two thirds o the lip require local aps
such as Abbe or Estlander.
5. B. Basal cell carcinoma is the most common orm
o skin cancer ollowed by squamous cell carcinoma.
C H AP TER 1 1 S k I N C AN C ER 43
Basal cell carcinoma o en presents as pearly nod-
ules with telangiectases and may bleed occasionally.
A skin biopsy to establish a diagnosis is important
be ore treatment o any skin cancer. Margins or
low risk squamous cell carcinoma range rom 0.5 to
1.0 cm. Margins or low risk basal cell carcinoma
range rom 0.3 to 0.5 cm. Additionally, Mohs micro-
surgery is considered an option in non-melanoma
skin cancers. Bottom line, squamous cell carcino-
mas most o en arise in chronically damaged skin or
within actinic keratosis, in burn scars, and chronic
in ammatory wounds.
BIBLIOGRAPHY
Allen PJ, Bowne WB, Jaques DP, et al: Merkel cell carcinoma:
Prognosis and treatment o patients rom a single institu-
tion. J Clin Oncol. 2005;23:23009.
Campbell JP. Surgicla management o lip carcinoma. J Oral
Maxillofac Surg. 1998;56:955.
Cole MD, Jakowatz J, Evans GR. Evaluation o nodal patterns
or melanoma o the ear. Plast Reconstr Surg 2003;112:506.
Diepgen L, Mahler V. T e epidemiology o skin cancer. Br J
Dermatol. 2002;146:16.
Feng H, Shuda M, Chang Y, Moore PS. Clonal integration o
a polyomavirus in human Merkel cell carcinoma. Science.
2008. 319:1096100.
Funk GF, HyndsKArnell L, Robinson RA, et al. Presentation,
treatment, and outcome o oral cavity cancer: a National
Cancer Data Base Report. Head Neck. 2002;24:165.
Jemal A1, Siegel R, Ward E, Hao Y, Xu J, Murray , et al. Cancer
statistics, 2008. CA Cancer J Clin. 2008;58:7196.
Odgson NC: Merkel cell carcinoma: Changing incidence
trends. J Surg Oncol. 2005;89:14.
Pockaj BA, Jaroszewski DR, DiCaudo DJ, et al. Changing sur-
gical therapy or melanoma o the external ear. Ann Surg
Oncol. 2003;10:68996.
Rubin AI, Chen EH, Ratner D: Basal cell carcinoma. N Eng J
Med. 2005;353:22629.
Usam KJ, Jungbluth AA, Rekthman N, et al. Merkel cell poly-
omavirus expression in Merkel cell carcinomas and its
absence in combined tumors and pulmonary neuroendo-
crine carcinomas. Am J Surg Pathol. 2009;3:137885.
 12
Decubitus Ulcers

Pamela C. Masella and Mark K. Markarian

You are consulted on a 35 year-old male, who other- A. Chronic wounds

wise healthy, was initially admitted 26 days ago in B. Diabetic wounds
septic shock secondary to a necrotizing so tissue C. Wound location
in ection o the right lower extremity. He required D. Meshed skin gra s
high-dose vasopressors or several days ollowing E. Wounds that require hemostasis
emergent operative debridement and institution o
broad-spectrum antibiotics. He was recovering well 3. Which o the ollowing patients would be the best
in the ICU and was recently extubated. However he candidate or ap reconstruction?
developed tachycardia, ever, and leukocytosis. T e A. A 48-year-old male with Stage I sacral ulcer and
ICU team calls you to evaluate because they are unable has no medical comorbidities
to identi y a source o in ection. You examine his back B. A 34 year-old male recovering rom brain injury
and nd a pressure sore overlying the right ischial with a Stage IV ischial ulcer that recently under-
tuberosity approximately 4 5 cm in size with a black went treatment or osteomyelitis
eschar overlying, expressible malodorous uid, and C. A 74-year-old homeless male with Stage III
surrounding cellulitis. sacral ulcer
D. A 48-year-old poorly controlled diabetic male
1. What is the stage o this pressure ulcer? with Stage III pressure sore overlying the right
A. Stage I greater trochanter
B. Stage II E. A 56-year-old male with Stage III chronic sacral
C. Stage III ulcer who re uses to stop smoking despite hospi-
D. Stage IV talization
E. Unstageable
4. Multiple options or treatment o pressure sores
2. Surgery is per ormed and when the black eschar exist. Which o the ollowing options should be
is removed, purulent uid is expressed. A er avoided?
extensive operative debridement to healthy tissue, A. Primary closure
you f nd that the wound extends to bone. Which B. Local wound care
o the ollowing would preclude use o Negative C. Skin gra s
Pressure Wound T erapy (NPW )? D. Musculocutaneous reconstruction
E. Fasciocutaneous reconstruction

ANSWERS
1. E. Accurate staging o pressure wounds is important
because it guides management. Staging is as ollows:
Stage I: Non-blanchable erythema o intact skin;
impending skin ulceration.
Stage II: Partial-thickness skin loss involving epider-
mis and/or dermis; ulcer is super cial and presents
clinically as an abrasion, blister, or shallow crater.
Stage III: Full-thickness skin loss involving dam-
age or necrosis o subcutaneous tissue that may
extend down to, but not through, underlying as-
cia; ulcer presents clinically as a deep crater with
or without undermining o adjacent tissue.
Stage IV: Full-thickness skin loss with extensive
destruction, tissue necrosis, or damage to muscle,
bone, or supporting structures.
Unstageable/Unclassi ed: T ere are also unstage-
able pressure sores that are commonly incorrectly
staged. T ese are pressure sores with slough/eschar
than need to be debrided be ore one can see how
deep they truly are, and can then be accurately staged.
Suspected Deep issue Injury: Purple or maroon
localized area o discolored intact skin or blood-
lled blister due to damage o underlying so tissue
rom pressure and/or shear.
2. E. Negative pressure wound therapy (NPW ) is
becoming a valuable resource used by surgeons to
manage di cult wounds. NPW devices consist o
an adhesive semi-occlusive dressing, tubing con-
nected to a collection canister and a vacuum source,
and an inter ace material to distribute the vacuum
(open-pore polyurethane hydrophobic oam).
Negative pressure on the sealed, airtight wound
results in:
Increased blood ow to the wound
Removal o excess uid that may retard cell
growth and proli eration
Micro- and macro-de ormation o the wound:
Macrode ormation is the visible stretch that
occurs when the sponge contracts. It serves to
draw the wound edges together, provide direct
and complete wound bed contact, distribute
negative pressure, remove exudate and in ec-
tious materials.
Microde ormation occurs at the cellular level
and leads to cell stretch. It reduces edema, pro-
motes per usion, and promotes granulation
C H AP TER 1 2 D EC u b i Tu s u l C ERs 45
tissue ormation by acilitating cell migration
and proli eration
Maintenance o wound homeostasis: the semi-
occlusive dressing and oam with insulation qualities
minimizes evaporation, desiccation, and heat loss
T e ollowing are common indications or nega-
tive pressure wound therapy:
Chronic, diabetic wounds or pressure ulcers
Meshed gra s (be ore and a er)
Flaps
Chronic and acute wounds
Subacute wounds (dehisced incisions)
T e ollowing are contraindications to negative
pressure wound therapy:
Fistulae to organs/body cavities
Necrotic tissue that has not been debrided or
eschar
Untreated osteomyelitis
Wounds that require hemostasis
Placing dressing on exposed blood vessels (includ-
ing anastomotic sites) or organs
Wound malignancy
Caring or the pressure sore patients involves
more than addressing the wound. Wound healing in
chronic wounds requires a systemic strategy, includ-
ing nutritional assessment and maintenance, control
o both systemic and local in ection, avoidance o
excessive moisture/incontinence, pressure and mus-
cle spasm relie , surgical debridement and wound
closure.
3. B. Most commonly, Stage III/IV pressure sores are
re erred or so tissue reconstruction. Un ortunately
some o these patients are not suitable candidates or
medical or social reasons. Since these surgeries are
requently raught with complications, there are multi-
ple patient characteristics to optimize be ore coverage
can be considered:
Nutritional status
Control o medical comorbidities
Presence o muscle spasticity (Can this be con-
trolled with anti-spasmodics?)
obacco dependence
Social situation (assess or presence o a responsi-
ble caretaker at homeand subsequent appropri-
ate residence at own home vs acility), appropriate
specialty mattress at residence, strict regimen o
46 G EN ERAl s u RG ERY EXAM i N ATi O N AN D b O ARD REVi EW
requent turning to prevent ap necrosis/ ailure,
appropriately padded wheelchair
I osteomyelitis is present, then the patient likely
needs bony debridement and tailored IV antibiotic
therapy (typically or 6 weeks) be ore so tissue
reconstruction can be attempted.
Consideration o adverse drug actors like use o
steroids or immunosuppressants
Control o dif erent causes o maceration like
ecal or urine incontinence
Medical non-compliance
Once these medical/social issues are addressed,
the wound can then be optimized with thorough
debridement and dressing care, in preparation or
ap reconstruction.
4. A. When planning therapeutic treatment o pres-
sure sores, the choice o closure strategy depends
not only on the location, size, and depth o the ulcer,
but also on the previous management strategies
employed. Primary closure should be avoided. T ese
wounds tend to have an absence o adequate tissue
and primary closure leads to tension, scarring over
the original bony prominence, and dehiscence. Skin
gra ing has a limited success rate, as gra ing tends to
provide unstable coverage. Musculocutaneous aps
provide adequate blood supply, bulky padding, and
are ef ective in treating in ected wounds. Fasciocuta-
neous aps of er an adequate blood supply, durable
coverage, and low rates o unctional de ormity.
BIBLIOGRAPHY
Bauer JD, Mancoll JS, Phillips LG. Pressure Sores. In: T ome,
CH. Grabb and Smiths Plastic Surgery. Fi h ed. Philadel-
phia: Lippincott Williams & Wilkins, 2007;72229.
European Pressure Ulcer Advisory Panel and National Pres-
sure Ulcer Advisory Panel. Prevention and treatment o
pressure ulcers: quick re erence guide. Washington DC:
National Pressure Ulcer Advisory Panel; 2009.
KCI. T e V.A.C. therapy clinical guidelines: a re erence source
or clinicians [report on the Internet]. 2005. Kinetic Con-
cepts, Inc. 7-1-2006.
Ohjimi H1, Ogata K, Setsu Y, et al. Modi cation o the glu-
teus maximus V-Y advancement ap or sacral ulcers: the
gluteal asciocutaneous ap method. Plast Reconstr Surg.
1996;98(7):124752.
 13
Melanoma

Amber E. Ritenour and Lauren Greer

A 50-year-old Caucasian emale was re erred to general 4. Regarding sentinel lymph node biopsy in patients
surgery by her primary care provider or evaluation o a with melanoma, which of the following is FALSE?
mole to her le medial cal . On examination o her le A. Completion lymph node dissection is recom-
medial cal , she has a 9 mm diameter pigmented lesion mended to achieve regional control in melanoma
with irregular borders and color variation. Excisional patients with positive sentinel lymph nodes.
biopsy is per ormed. B. Sentinel lymph node biopsy is indicated or inter-
mediate thickness melanomas (Breslow thickness,
1. Pathology will most likely show which histologic
1 to 4 mm) regardless o ulceration or mitotic rate.
subtype of melanoma?
C. Sentinel lymph node biopsy is indicated or stag-
A. Acral lentiginous ing in patients with thick melanomas ( 4; Breslow
B. Desmoplastic thickness > 4 mm).
C. Lentigo maligna D. In patients with clinically localized melanoma,
D. Nodular sentinel node status is the most important prog-
E. Super cial spreading nostic indicator.
E. Sentinel lymph node biopsy is mandatory in all
2. If her melanoma is 2.2 mm thick, the surgical skin
patients with thin melanomas (< 1 mm) i there
margin for a wide local excision of the primary
are high-risk eatures.
lesion should be at least
A. 0.5 cm 5. Regarding metastatic melanoma, which of the
B. 1 cm following is FALSE?
C. 2 cm A. Surgery or patients with Stage IV melanoma
D. 3 cm con ers a survival advantage over systemic medi-
E. 4 cm cal therapy alone.
B. T e primary objective o metastatectomy or Stage
3. Which of the following is a poor prognostic
IV melanoma is resection o all known disease.
indicator in melanoma patients?
C. Recurrent Stage IV disease is not a contraindica-
A. Extremity location tions to surgery or metastatic melanoma.
B. Low Breslow thickness D. In-transit metastases occur less than 2 cm rom
C. Female gender the primary melanoma and are located between
D. Elevated LDH the primary melanoma and the regional lymph
E. Younger age node basin.
E. More than 50% o patients with Stage IV mela-
noma will develop brain metastases.
48 G EN ERAL S U RG ERY EXAM I N ATI O N AN D BO ARD REVI EW
ANSWERS
1. E. Seventy- ve percent o all malignant melanomas
are super cial spreading melanomas. Most arise de
novo but they may be associated with a pre-existing
nevus. T ey grow radially be ore growing vertically.
ypical locations are in sun-exposed areas, namely
the back in men and legs in women. Nodular mela-
nomas comprise 15% to 30% o melanomas and are
o en dome-shaped and dark. T ey quickly develop
a vertical growth phase. Lentigo maligna melanoma
typically develops as a brown macule in sun dam-
aged skin o older individuals and may grow radi-
ally or years be ore vertical growth develops. Acral
lentiginous melanoma is the rarest melanoma in
caucasians but is the most common type in Asians
and dark-skinned people. T ey are aggressive and
commonly arise on palmar, plantar, subungual, and
mucosal sur aces. Desmoplastic melanoma is a rare
variant that may be mistaken or a scar, broma other
benign lesion and should be re erred to an experi-
enced dematopathologist or evaluation.
2. C. Wide local excision is standard treatment or
melanoma. Excision should be carried through skin
and subcutaneous tissue down to muscle ascia. Cur-
rent recommendation is or 0.5 to 1 cm margins
or melanoma in situ, 1cm margins or melanomas
1 mm thick, 1 to 2 cm or melanomas 1.01 to
2 mm thick, and 2 cm margins or melanomas > 2 mm.
A randomized multicenter trial demonstrated no
bene t to 4 cm versus 2 cm margins in patients with
melanomas > 2 mm thick. Other trials have corrobo-
rated these results.
3. D. Evidence based prognostic indicators were care-
ully considered and integrated into the current
AJCC staging system to provide staging that re ects
disease biology. In 2001, Balch et al. published a
prospective study o 17,600 melanoma patients to
determine actors that were predictive o melanoma-
speci c survival. T e investigators determined that
patients with melanomas o the head, neck, or trunk
had a signi cantly worse survival rate than patients
with melanomas o the extremities. Males had a
poorer prognosis than emales. Increasing Breslow
thickness was predictive o lower survival.
Presence o ulceration was more requent among
patients with thick melanomas (63% ulceration,
Breslow thickness < 4 mm) than among patients with
thin melanomas (6%, Breslow thickness 1 mm).
At all thickness levels, patients with ulcerated mel-
anomas were ound to have survival curves that
were similar to patients with melanomas o the next
higher Breslow thickness. T e investigators ound
a signi cant step-wise decrease in survival based
on increasing age. Patients with higher number o
nodal metastases and patients with macrometastases
(clinically palpable nodes) also had poorer survival.
Seetharmu et al. (Oncology. 2011;81(56):4039)
ound that elevated pre-treatment LDH was corre-
lated with poorer 2 year survival in Stage IV mela-
noma patients. umor mitotic rate has also been
determined to be a signi cant prognostic indicator.
4. E. Metastasis to regional lymph nodes is the most
important prognostic actor in patients with early
stage melanoma. T e American Society o Clini-
cal Oncology (ASCO), Society o Surgical Oncology
Joint Clinical Practice Guideline, and T e National
Comprehensive Cancer Network (NCCN) Guidelines
Version 4 (2014) recommend routine sentinel lymph
node biopsy in patients with patients with intermedi-
ate thickness melanomas (Breslow thickness 14 mm).
Although there is less data to support use o senti-
nel lymph node biopsy in thick melanomas (Breslow
thickness > 4 mm), sentinel node biopsy is recom-
mended to acilitate accurate staging. ASCO guide-
lines state that there is insu cient evidence to support
routine sentinel node biopsy in thin melanomas (Bres-
low thickness < 1 mm), but it may be considered in
patients with high risk eatures. NCCN guidelines state
that sentinel lymph node biopsy is not generally indi-
cated in patients with Breslow thickness 0.75 mm.
However, consideration should be given to sentinel
lymph node biopsy in patients with Breslow thickness
0.761 mm, especially i ulceration or mitotic rate
1 per mm is present. Completion lymph node dis-
section remains the standard recommendation or
patients with tumor positive sentinel nodes. Current
evidence suggests that completion lymph node dissec-
tion is ef ective at achieving local control. T e ongo-
ing Multicenter Selective Lymphadenectomy rial II
(MSL II) is investigating whether completion lymph
node dissection also improves survival. Current AJCC
staging re ned N categories to account or the prog-
nostic dif erence between patients with clinically
palpable (macrometastasis) and clinically negative but
pathologically positive sentinel nodes (micrometastasis).

5. D. In appropriately selected patients with Stage IV
melanoma, surgery should be considered as ini-
tial therapy. Analysis o MSL -1 data demonstrated
improved survival in patients with Stage IV mela-
noma who underwent surgery with or without sys-
temic medical therapy compared with systemic
medical therapy alone. Multiple sites o disease and
even recurrent Stage IV disease are not contraindica-
tions to resection. T e most important preoperative
considerations include resectability o all known dis-
ease, tumor biology such as tumor volume doubling
time, and patient comorbidities. T e most common
metastatic sites or melanoma are skin, lung, lymph
nodes, brain, liver, and gastrointestinal tract.
In-transit metastasis is de ned as intra-lymphatic
tumor in skin or subcutaneous tissue more than 2 cm
rom the primary tumor but not beyond the near-
est regional lymph node basin. T e lung is a typical
site o metastasis and good evidence or pulmonary
metastatectomy exists. Melanoma is the most com-
mon metastatic tumor in the small bowel and may
present as pain, obstruction, bleeding, palpable mass
or weight loss. More than 50% o patients with Stage
IV melanoma will develop brain metastasis. Because
o this, NCCN Version 4 (2014) Melanoma recom-
mends consideration o annual brain MRI in addition
to more requent whole body PE /C as a part o
routine surveillance in patients with Stage IV disease.
BIBLIOGRAPHY
Azzola MF, Shaw HM, T ompson JF, Soong SJ, Scolyer RA,
Watson GF, et al. umor mitotic rate is a more power ul
prognostic indicator than ulceration in patients with pri-
mary cutaneous melanoma: an analysis o 3661 patients
rom a single center. Cancer. March 2003;97(6):148898.
Balch CM, Soong SJ, Smith , Ross MI, Urist MM, Karakousis
CP, et al. Long-term results o a prospective surgical trial
comparing 2 cm versus 4 cm excision margins or 740
patients with 1 to 4 mm melanomas. Ann Surg Oncol.
March 2001;8(2):1018.
C H AP TER 1 3 M ELAN O MA 49
Balch CM, Urist MM, Karakousis CP, Smith J, emple WJ,
Drzewiecki K, et al. E cacy o 2-cm surgical margins or
intermediate-thickness melanomas (1 to 4 mm). Results o
a multi-institutional randomized surgical trial. Ann Surg.
September 1993;218(3):2627; discussion 2679.
Balch CM, Soong SJ, Gershenwald JE, T ompson JF, Reintgen
DS, Cascinelli N, et al. Desmoplastic malignant melanoma
(a rare variant o spindle cell melanoma). Cancer. 1971;
28(4):914.
Desmond R, Zhang Y, Liu PY, Lyman GH, Morabito A. Prog-
nostic actors analysis o 17,600 melanoma patients:
Validation o the American Joint Committee on Cancer
melanoma staging system. Journal of Clinical Oncology.
August 2001;19(16):362234.
Dzwierzynski WW. Managing malignant melanoma. Plastic and
Reconstructive Surgery. September 2013;132(3):446e60e.
Gillgren P1, Drzewiecki K , Niin M, Gullestad HP, Hellborg
H, Mnsson-Brahme E, et al. wo cm versus our cm sur-
gical excision margins or primary cutaneous melanoma
thicker than two mm: A randomised, multicentre trial.
Lancet. November 2011;378(9803):1626.
Howard JH, T ompson JF, Mozzillo N, Nieweg OE, Hoekstra
HJ, Roses DF, et al. Metastasectomy or distant metastatic
melanoma: Analysis o data rom the rst Multicenter Selec-
tive Lymphadenectomy rial (MSL -I). Annals of Surgical
Oncology. August 2012;19(8):254755.
Leung AM, Hari DM, Morton DL. Surgery or distant mela-
noma metastasis. Cancer J. 2012;18:17684.
McGovern VJ, Mihm MC Jr, Bailly C, Booth JC, Clark WH
Jr, Cochran AJ, et al. T e classi cation o malignant mela-
noma and its histologic reporting. Cancer. 1973;32(6):
1446.
National Comprehensive Cancer Network (NCCN) Clinical
Practice Guidelines in Oncology: Melanoma,Version 4 Web
site. Accessed rom http://www.nccn.org/pro essionals/
physician_gls/ _guidelines.asp. Published 2014.
Seetharamu N, u J, Christos P, Ott PA, Berman RS, Shap-
iro RL, et al. Enrollment in clinical trials correlates with
improved survival in metastatic melanoma. Oncology. 2011;
81(56):4039.
Wong SL, Balch CM, Hurley P, Agarwala SS, Akhurst J,
Cochran A, et al. Sentinel lymph node biopsy or mela-
noma: American Society o Clinical Oncology and Society
o Surgical Oncology joint clinical practice guideline. J Clin
Oncol. Aug 2012;30(23):29128.
 14
Sarcoma and Lymphoma
Joshua S. Ritenour
SCENARIO 1
A 47-year-old emale presents with a several months
history o a slowly growing painless mass in her right
thigh. On physical exam, she is noted to have a 5 cm
rm, non-tender mass in the right lateral mid-thigh.
1. Which o the ollowing is true?
A. Routine imaging o the mass should include a
PE scan.
B. Incisional biopsy should be routinely per ormed
in order to con rm the diagnosis and identi y
the histological subtype.
C. T e most common histologic subtypes or
extremity sarcomas include liposarcoma and
malignant brous histiocytoma.
D. Staging includes an abdominal and pelvic C
scan to evaluate or metastatic disease in this
lesion.
E. Multidisciplinary evaluation is not needed or
simple, early-stage sarcomas.
2. Regarding surgical management o this patient,
which o the ollowing is true?
A. A unctional outcome is the highest priority.
B. Surgical margin o 1 to 2 cm should be sought
whenever possible.
C. Regional lymph node dissection is also required.
D. Amputation should be strongly considered as the
primary therapy or most extremity sarcomas.
E. Histologic subtype has little impact on surgical
planning.
3. Regarding neoadjuvant and adjuvant therapies or
sof tissue sarcoma, which o the ollowing is true?
A. Chemotherapy is the most important therapeutic
intervention or outcomes rom sarcoma.
B. Metastatectomy has no role in the management
o sarcomas.
C. Radiation therapy has been shown to be o
bene t in the treatment o sarcomas.
D. Local recurrence is rare a er appropriate therapy.
E. Gastrointestinal stromal tumors (GIS ) are
treated similarly to other sarcomas.
SCENARIO 2
A 26-year-old male presents with a painless mass in his le
axilla that has been present or several months. Upon ques-
tioning, he endorses unexplained low-grade evers, night
sweats, and an unplanned weight loss o 10 lbs over the
previous 3 months. On physical exam, he is noted to have
a 2 cm rm, rubbery, non-tender mass in the le axilla.
4. Which o the ollowing considerations is true or this
patient?
A. Observation is warranted.
B. History o ever, chills, night sweats, and weight
loss are considered A level symptoms.
C. Physical examination should include thorough
exam o all accessible lymph node basins as well
as potential sites o a primary malignancy.
D. Sexually transmitted diseases can be ruled out by
physical exam in younger patients.

E. Fine-needle aspiration (FNA) biopsy o suspicious
lymph nodes in this patient is usually adequate or
diagnosis.
5. Regarding lymphoma, which o the ollowing is
true?
A. Surgeons play a major role in the treatment o
lymphoma.
B. T e hallmark o treatment is surgery and chemo-
therapy.
C. Staging or Hodgkins lymphoma is based upon
a di erent staging system than is Non-Hodgkins
lymphoma.
D. HIV in ection has been shown to increase the
incidence o lymphoma but other immunosup-
pressive states have not.
E. Mucosa-associated lymphoid tissue (MAL )
lymphoma may be de nitively treated with H.
pylori eradication in its early stages.
2. B. Until the early 1980s, amputation remained a pri-
ANSWERS
1. C. Regarding pre-operative imaging o the tumor,
MRI is generally pre erred or extremity sarcomas,
while C tends to be pre erable or abdominal and
retroperitoneal sarcomas. However, there has not
been demonstrated a statistically signi cant di er-
ence between the two modalities. High quality cross
sectional imaging is nevertheless critical or pre-
operative evaluation and planning. PE can give
in ormation regarding the grade, prognostication,
and response to chemotherapy in select high grade,
large, deep sarcomas, and can be considered or use,
but does not have a role in routine evaluation o all
sarcomas.
Incisional biopsy may be required, but gener-
ally speaking, or both extremity and retroperito-
neal sarcomas, needle core biopsy (with or without
image guidance) provides adequate tissue sampling
with good diagnostic correlation to nal pathology.
However, when unavailable or inadequate, incisional
biopsy or extremity sarcomas remains a reasonable
diagnostic option. Care should be taken i an incisional
biopsy is necessary. Incisions should be oriented lon-
gitudinally and thought ully, as re-excision o biopsy
site will be necessary with de nitive operation. In
some selected institutions with clinical and patho-
logic expertise, FNA may be adequate, but should
probably not be considered adequate at low-volume
centers.
C H AP TER 1 4 S ARCo m A An d Ly m P H o m A 51
T ere are over 50 histologic subtypes o so tis-
sue sarcoma recognized. Overall, the most common
subtypes are liposarcoma, malignant brous histio-
cytoma (MFH), and leiomyosarcoma, however the
prevalence is site speci c. T e most common types
or extremity sarcomas are liposarcoma and MFH,
while retroperitoneal sarcomas are more commonly
liposarcoma and leiomyosarcoma. GIS and leiomyo-
sarcoma are the histological types ound in visceral
tumors.
Overall, lung is the most common site o metasta-
sis or extremity sarcomas. For visceral tumors, liver
is more common. Chest C is generally advocated
or extremity sarcomas to rule out metastatic disease.
Due to the complexity, rarity, and histology-
based therapy or so tissue sarcomas, prior to ini-
tiating therapy, all patients should be evaluated by
a multidisciplinary team with expertise in sarcoma
therapy.
mary therapy or most extremity sarcomas. In 1982,
Rosenberg and colleagues at the National Cancer
Institute published a randomized trial o amputation
vs. limb-sparing surgery plus radiation and demon-
strated equivalent overall survival and acceptable
local recurrence rate o 15% with limb-salvage versus
0% with amputation. Currently, limb salvage surgery
can be sa ely per ormed in over 90% o patients with
extremity sarcoma with excellent local recurrence
rates. Proximity o critical structures (bone, nerves,
blood vessels, etc.) should be considered care ully
during pre-operative planning and the expected
unctional outcome assessed to assist in making the
decision or limb salvage versus amputation.
Care ul pre-operative planning is imperative
or success ul resection o these tumors. Failure to
obtain a negative surgical margin is the most impor-
tant risk actor or local recurrence. Care ul scrutiny
o pre-operative imaging can result in improved out-
comes by allowing the surgeon to have a thorough
understanding o the extent o the tumor and rela-
tionship to local structures. Functional outcomes are
also improved by care ul consideration o the extent
o resection required. Similarly, this allows or appro-
priate consultation with subspecialists including
plastic or vascular surgeons pre-operatively when
anticipated being necessary.
Wide margins should be the goal o therapy. A
margin o 1 to 2 cm o normal tissue can help to
52 G En ERAL S U RG ERy EXAm In ATI o n An d Bo ARd REVIEW
minimize the risk o local recurrence. However,
strong tissues such as ascia can severely limit the
spread o most types o sarcoma into adjacent struc-
tures. T ere ore, a narrow ascial margin may be
acceptable where such a narrow margin o muscle or
at would likely result in an increased risk o recur-
rent disease. In some cases, such as retroperitoneal
sarcomas, wide margins may not be easible.
Resection o nerves and blood vessels is occasion-
ally unavoidable, but can o en be avoided by care ul
skeletonization o blood vessels and resection o the
perineurium along with the tumor. T e concept o
planned positive margin is easible in many cases
with the use o adjuvant radiation therapy. As long
as the structure o concern is not xed to the tumor,
this care ully planned positive margin provides simi-
lar outcomes to controls with negative margins. Neo-
adjuvant radiation has been advocated in this setting
or marginally resectable tumors in order to allow a
negative margin unctional resection.
Histologic subtype does play an important actor
in planning surgical intervention. Well-di erentiated
liposarcoma ( ormerly called atypical lipomas) have
similar recurrence rate to other types o sarcoma, but
metastatic disease is rare, so surgical resection can
be less aggressive when necessary. Dermato brosar-
coma protuberans (DFSP) and myxo brosarcoma
are particularly di cult due to the common nding
o microscopic tentacles that extend laterally rom
these lesions. DFSP has a tendency to respect ascial
borders, whereas myxo brosarcoma o en penetrates
ascia and can have multi ocal skip lesions, so these
actors must be considered. Lymph node metastasis
is rare in S S in general, but can be seen more com-
monly with epithelioid or clear cell variants. For this
reason, sentinel lymph node biopsy can give prognos-
tic in ormation, so though no clear therapeutic bene t
has been shown, it may be considered in this setting.
3. C. Radiation therapy has been repeatedly demon-
strated to be o bene t in disease ree survival, though
not signi cantly di erent overall survival. T ere
remains some controversy regarding the optimal tim-
ing o the radiation therapy. When comparing neo-
adjuvant versus adjuvant therapy, local control rate
is similar. However, preoperative radiation has been
ound to double wound complications in the months
ollowing surgery compared to increased rates o long
term complications such as brosis, edema, and joint
sti ness with postoperative radiation. External beam,
brachytherapy, and intraoperative radiotherapy have
all been used with some success. Patients at low risk
or recurrence (i.e., small (< 5 cm) super cial tumors,
low grade tumors, wide surgical margins) may not
derive a signi cant bene t rom radiation and may be
treated with surgery alone.
Surgery is the dominant therapeutic modality or
extremity, retroperitoneal, and visceral sarcomas.
Complete surgical resection is the primary actor
in outcomes. Only a ew clinical trials have dem-
onstrated a statistically signi cant improvement
in outcomes with adjuvant chemotherapy. Speci c
histology-directed regimens have shown the most
promise and have achieved excellent and sustained
results in speci c subtypes to include gastrointestinal
stromal tumors (GIS ), rhabdomyosarcoma, Ewing
sarcoma, and osteosarcoma.
Patients with an isolated metastasis can be consid-
ered or metastatectomy i resection with or without
chemotherapy or radiation may result in a cure. T is
may include removal o limited disease in a single
organ or regional node dissection i nodal metasta-
sis is isolated. Speci cally in the setting o isolated
lung metastasis, median survival is lengthened rom
11 to 33 months compared to observation. Patients
with widely metastatic disease may be considered
or palliation using a variety o modalities including
surgery, chemotherapy, radiation, embolization, and
ablation procedures.
Local recurrence rate varies with the site o the
initial tumor and the adequacy o surgical resection,
but is signi cant. Local recurrence a er treatment
or extremity so tissue sarcoma approaches one out
o three patients. T e median disease- ree interval
is 18 months, but can be quite remote. Considera-
tions or treatment o recurrent disease are similar to
primary disease and can include reexcision, chemo-
therapy, and radiation, o en with similar success to the
primary tumors or extremity sarcomas. Recurrence o
visceral and retroperitoneal sarcomas o en is unable
to be completely re-excised.
GIS is the most common mesenchymal tumor
o the GI tract, and has gained signi cant inter-
est in recent years. T e discovery o the KI proto-
oncogene mutation present in the majority o GIS
tumors led to the ability to speci cally target GIS
tumors at a molecular level with the tyrosine kinase
inhibitor imatinib mesylate (Gleevec; Novartis
Pharmaceutical, Basel, Switzerland). T is advance-
ment marks a new era in treating solid tumors with

speci c molecular targeting. Surgery remains o
vital importance, but several studies have demon-
strated improved disease- ree and overall survival
or patients at signi cant risk or recurrence who are
treated adjuvantly with tyrosine kinase inhibitors, so
this has become an important, disease-speci c therapy
or these rare tumors.
4. C. In patients without a tissue diagnosis o malig-
nancy, but concern or lymphoma, FNA is generally
not considered to be adequate or diagnosis. FNA
may be able to identi y some cases o metastatic
carcinoma (i.e., breast, lung, etc.) but is limited in
hematologic malignancies (especially lymphoma) as
lymph node architecture is a critical pathologic com-
ponent o making these diagnoses. FNA may be use-
ul in searching or recurrent disease. As knowledge
and use o molecular markers is expanded in the
uture, FNA may become a viable alternative to open
biopsy o suspicious nodes. When lymphadenopathy
is generalized the largest, most suspicious, and acces-
sible note is selected or biopsy. T e diagnostic yield
does vary by site with inguinal nodes having the low-
est yield and supraclavicular nodes the highest. Care-
ul and appropriate handling o tissue specimens is
critical to allow pathologic diagnosis. Adequate tissue
sampling is critical to allow assessment o nodal archi-
tecture. Specimens should be submitted to pathology
dry or in saline, not ormalin or other preserva-
tive, in order to allow f ow cytometric and immu-
nohistochemical studies to supplement traditional
pathology.
T e di erential diagnosis or lymphadenopathy
is extremely broad and includes malignancy (lym-
phoma, metastatic disease), in ections (cat-scratch
disease, HIV, mononucleosis, tuberculosis, etc.), auto-
immune disorders, iatrogenic causes such as medica-
tions and unusual causes including sarcoidosis and
Kawasakis disease. A thorough history and physical
can be used to help narrow this broad di erential. In
patients without concerning signs or symptoms sug-
gestive o malignancy or other severe disease (e.g.,
B symptoms, etc.) a period o observation o our
to six weeks is appropriate. I the lymphadenopathy
persists beyond this period o observation, urther
evaluation to include CBC and chest X-ray should be
pursued. Other testing to include serology or CMV,
heterophile testing (monospot), PPD, HIV testing,
RPR, and so on may be utilized based upon the his-
tory and physical and speci c concerns. Several
C H AP TER 1 4 S ARCo m A An d Ly m P H o m A 53
non-speci c laboratory tests ref ecting inf ammation
to include ESR, CRP, and brinogen may be used, but
do not typically help narrow the di erential diagno-
sis. Lactate dehydrogenase (LDH) is o en similarly
non-speci c though very high levels may suggest
a lymphoid neoplasm. Ultimately, persistent lym-
phadenopathy without an obvious etiology warrants
lymph node biopsy as discussed above.
Fever, chills, night sweats, and weight loss > 10%
over 6 months are the classically described B symp-
toms associated with lymphoma and the presence o
these ndings should increase the suspicion o this
diagnosis and prompt a more aggressive approach to
diagnosis.
Care ul physical exam should be an important part
o the evaluation o every patient with lymphadenop-
athy. T e di erential diagnosis is highly dependent
upon the presence o generalized versus isolated lym-
phadenopathy and the lymph node basin involved
when localized. Examining sites o possible meta-
static spread, or example breast, skin, oropharynx,
and so on is important in narrowing the di erential.
5. E. Lymphoma re ers to a spectrum o diseases
including Hodgkins and Non-Hodgkins (NHL) lym-
phomas with multiple subtypes within each group.
T e role o the surgeon in patients with lymphoma
is limited. By ar, the most important role o the sur-
geon is in assisting with the diagnosis by means o
lymph node biopsy. Once the diagnosis has been
made, the treatment o lymphoma is overwhelmingly
the role o chemotherapy and radiation. Historically,
surgery was more involved through the use o stag-
ing laparotomy, but this is now rarely indicated with
the availability and use o PE /C or staging pur-
poses. Surgical intervention to include splenectomy
is limited to signi cantly symptomatic situations
such as anemia, thrombocytopenia, neutropenia and
massive splenomegaly, and should be done only in
close consultation with oncology.
Staging or lymphoma is based upon modi ca-
tions o the original Ann Arbor classi cation, ini-
tially described or Hodgkins lymphoma, but now
also used or NHL. Staging is based upon number
and location o lymph node groups, extra-nodal
involvement, and has modi ers to signi y presence
or absence o B symptoms.
Several risk actors or lymphoma have been
identi ed. T ere has been a signi cant increase in
incidence since the 1970s, which has been partially
54 G En ERAL S U RG ERy EXAm In ATIo n An d Bo ARd REVI EW
explained by the HIV epidemic. Other contributors
to the increase include other in ections (i.e. Helico-
bacter pylori-induced mucosal associated lymphoid
tissue (MAL ) lymphoma), autoimmune diseases,
immunosuppression (as with organ transplant), envi-
ronmental actors including pesticides, and aging o
the population (NHL increases in incidence with age
and peaks during the h through seventh decades).
Hodgkins lymphoma is more common in higher
socioeconomic groups and less common in Asian
populations.
MAL lymphoma has been shown to be depend-
ent on Helicobacter pylori in ection. Gastric inf am-
matory response to this in ection stimulates the
acquisition o genetic abnormalities and malignant
trans ormation o B cells. In the early stages o this
disease, H. pylori eradication can reverse the disease
process in as many o 77% o patients. However, in
later stages o the disease, urther genetic injury to
these malignant cells make the tumor resistant to
bacterial eradication, so more aggressive therapy
including chemotherapy and radiation is indicated.
Like other orms o lymphoma, surgery is generally
reserved or rare situations with complication such
as li e-threatening hemorrhage.
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domized evaluations o (1) limb-sparing surgery plus radi-
ation therapy compared with amputation and (2) the role
o adjuvant chemotherapy. Ann Surg. 1982;196(3):30515.
Schuetze SM, Rubin BP, Vernon C, et al. Use o positron
emission tomography in localized extremity so tissue
sarcoma treated with neoadjuvant chemotherapy. Cancer.
2005;103(2):33948.
Singer S. So issue Sarcomas. In: ownsend DM, Beau-
champ RD, Evers BM, et al. eds. Sabiston extbook o Sur-
gery. Eighteenth ed. Pliladelphia, PA: Saunders Elsevier:
2008:78699.
aghizadeh M, Muscarella P. Splenectomy or hematologic
disorders. In: Cameron JL, Cameron AM. Current Surgi-
cal T erapy. enth ed. Philadelphia, PA: Elsevier Saunders:
2011:4739.
wist CJ, Link MP. Assessment o lymphadenopathy in children.
Pediatr Clin N Am. 2002;49(5):100925.
Wong SL. Sarcomas o so tissue and bone. In: Mulholland
MW, Lillemoe KD, Doherty GM, et al. Green elds Surgery:
Scientif c Principles and Practice. Fi h ed. Philadelphia, PA:
Lippincott Williams & Wilkins: 2010.
 15
T oracic Surgery
Lung CancerCough
Ashra A. Sabe
A 77-year-old male who is a ormer smoker (quit 10
years ago; smoked 1 pack per day or 50 years) with
COPD, type 2 diabetes mellitus, and CAD status post
CABG 3 10 years ago, presents with a 4 month history
o a non-productive cough and 10 pound weight loss
in the past 3 months. A CXR and C chest demonstrate
a 2 3.1 cm mass in his right upper lung that was not
present on a CXR taken 5 years earlier.
1. What is the best appropriate next step in the
management o this patient?
A. Positron emission tomography (PE ) scan
B. Cervical mediastinoscopy
C. Right upper lobectomy
D. Right upper lobectomy with mediastinal lymph
node sampling
E. Bone scan and abdominal C scan
2. Assuming this patient was diagnosed with a primary
non-small cell lung cancer (NSCLC) in the right
upper lobe o his lung, which o the ollowing is an
absolute contraindication to surgical resection?
A. A post-operative predicted FEV1 o 45%
B. A malignant pleural e usion in the right chest
C. umor directly invading the chest wall
D. umor directly invading the right main bronchus
0.5 cm away rom the carina
E. umor directly invading the mediastinal pleura
3. When per orming a right upper lobectomy, a er
the pleura overlying the anterior hilum are divided
rom anterior to posterior, what is the order o
structures that would need to be divided?
A. Superior pulmonary vein/Upper lobe bronchus/
runcus anterior
B. runcus anterior/Superior pulmonary vein/
Upper lobe bronchus
C. Superior pulmonary vein/ runcus anterior/
Upper lobe bronchus
D. Upper lobe bronchus/ runcus anterior/Superior
pulmonary vein
E. runcus anterior/Upper lobe bronchus/Superior
pulmonary vein
4. A er resection o his tumor by a right upper
lobectomy, pathology demonstrated squamous cell
carcinoma with negative margins. Lymph nodes
sampled were also negative or malignancy. Which
o the ollowing is true?
A. T e patient will not need any urther surveillance.
B. T e only surveillance needed will be a repeat C
chest in 2 years.
C. T e most common site o relapse or NSCLC is
bone.
D. T e patient will require radiation therapy or
6 months post-operatively.
E. Most recurrences occur within the rst two years
a er surgery.
5. I another patient presented with signif cant
hyponatremia and seizures and was incidentally
ound to have similar sized lung mass in the right
upper lobe, the patient would most likely benef t
rom which o the ollowing treatment modalities?
A. Surgical resection o the tumor alone
B. Single agent chemotherapy
56 G EN ERAL S U RG ERY EXAM I N ATI O N AN D BO ARD REVI EW
C. Radiation therapy alone
D. Combination chemotherapy alone
E. Combination chemotherapy and radiation therapy
ANSWERS
1. A. PE scanning uses uorodeoxyglucose (FDG)
with radiolabeled uorine to help detect malignant
cells. Malignant cells metabolize glucose at a higher
rate than normal cells, resulting in a radiolabeled
metabolite o FDG, which results in a visual marker
to help identi y malignant cells, nodal stage, and
metastases. Surgical resection without any attempt
at preoperative staging is not appropriate. Although
cervical mediastinoscopy may be an important step
in assessing the stage o this patients lung cancer,
PE scanning may identi y suspicious nodes and
distant metastasis and helps guide the surgeon on
where to obtain the appropriate tissue or diagnosis.
2. B. Surgery is contraindicated or Stage IIIB and IV
lung cancer. 4 lesions are classi ed as stage IIIB i
they are associated with N2 disease. umors o any size
are 4 i they invade the heart, great vessels, trachea,
esophagus, vertebral body, or carina. umors associ-
ated with malignant pleural or pericardial e usions
are considered to have M1A disease, which precludes
surgical intervention. 3 tumors include tumors o
any size that directly invade any o the ollowing: dia-
phragm, chest wall, mediastinal pleura, parietal peri-
cardium, or a tumor invading the main bronchus less
than 2 cm rom the carina (without involvement o the
carina). Depending on nodal and metastatic involve-
ment, 3 tumors may not result in a staging level o
IIIB or IV. T us, surgery may be appropriate in select
patients presenting with 3 tumors.
Preoperative testing o pulmonary unctional
reserve is essential prior to determining whether a
patient is a candidate or surgical resection. In gen-
eral, a predicted post-operative FEV1 less than 40% is
thought to be a contraindication to surgical resection.
Although a post-operative predicted FEV1 o 45% is
not an absolute contraindication to surgical resec-
tion, it certainly merits thorough preoperative patient
assessment (including evaluation o comorbidities,
and predicted lung di usion capacity). It is also impor-
tant to remember that i the lung to be resected is not
actually unctional (secondary to collapse or bronchial
obstruction) than the post-operative predicted FEV1
should not be expected to change signi cantly rom
the preoperative FEV1. Conversely, i the lung to be
resected happens to be unctional, but the patient has
other areas o lung that are non- unctional, than the
FEV1 will actually decrease more dramatically when
this unctional lung is resected.
3. C. Structures that would be need to be divided or a
right upper lobectomy rom anterior to posterior are
the superior pulmonary vein, truncus anterior, and
upper lobe bronchus. T is is a simpli ed description
o the most commonly encountered anatomy or the
main structures seen. During dissection the surgeon
must be mind ul o aberrant anatomy (o en noted
on preoperative imaging) and more commonly
branching vessels, which may appear in di erent
planes than listed above.
4. E. NSCLC is most likely to relapse within the rst two
years a er resection (over 60%). T us, oncologic sur-
veillance should be done every 3 to 4 months during
this time. T ough there is no single recommendation
or surveillance beyond 2 years, coordinated oncologic
surveillance should be per ormed long-term. T ough
relapse o NSCLC is common in the bone, the most
common site o relapse or all stages o NSCLC is the
brain. Other sites o relapse include the lung (ipsilat-
eral or contralateral), liver, and adrenal glands. T ere is
no indication or radiation therapy post-operatively.
5. E. Paraneoplastic syndromes develop in as many
as 40% o patients with newly diagnosed lung can-
cers. Signi cant hyponatremia in the setting o a
newly diagnosed lung mass is highly suspicious o
syndrome o inappropriate antidiuretic hormone
(SIADH). It is important to recognize that SIADH is
most commonly associated with small cell lung can-
cer (SCLC). In addition to hyponatremia, the diag-
nosis o SIADH is con rmed by demonstrating a
serum osmolarity < 275 mOsm/kg, urine osmolarity
> serum osmolarity, and urine sodium > 25 meq/L.
Associated symptoms may include lethargy, nausea,
vomiting, altered mental status, and seizures.
SCLC account or 20% o all lung cancers. T ese
tumors are known or rapid growth, and thus o en
present with necrosis. T ey commonly invade vas-
cular and lymphatic tissue, and metastasize early.
Up to 70% o patients present with metastasis at the
time o diagnosis. Given that SCLC is a systemic
disease, chemotherapy is the primary medical treat-
ment. Combination chemotherapy with the addition
 C H AP TER 1 5 TH O RAC I C S U RG ERY LU N G C AN C ER CO U G H
o radiotherapy or locoregional control has been
shown to improve survival. Additional prophylactic
cranial irradiation has been shown to decrease the
incidence brain metastasis, but has not been shown
to improve overall survival.
Other paraneoplastic syndromes associated with
hormone alterations should also be recognized.
O en Patients with SCLC may exhibit elevations in
adrenocorticotropic hormone (AC H). T is may
mani est with hypokalemia, hyperglycemia, and
metabolic alkalosis. Diagnosis can be con rmed by
measuring elevated AC H in the blood or elevated
17-hydroxycorticosteroid levels in the urine.
BIBLIOGRPAHY
Cook RM, Miller YE, Bunn PA Jr. Small cell lung cancer:
etiology, biology, clinical eatures, staging, and treatment.
Curr Probl Cancer. 1993;17(2):69141.
Cromartie RS, Parker EF, May JE, Metcal JS, Bartles DM. Car-
cinoma o the lung: a clinical review. T e Annals o thoracic
surgery. 1980;30:305.
Darnell RB, Posner JB. Paraneoplastic syndromes a ecting
the nervous system. Semin Oncol. 2006;33(3):27098.
Mountain CF. Revisions in the International System or Stag-
ing Lung Cancer. Chest. 1997;111:17107.
57
Martini N, Bains MS, Burt ME, Zakowski MF, McCormack P,
Rusch VW, et al. Incidence o local recurrence and second
primary tumors in resected stage I lung cancer. T e Journal
o thoracic and cardiovascular surgery. 1995;109:1209.
Morabito A, Carillio G, Daniele G, et al. reatment o small
cell lung cancer. Crit Rev Oncol Hematol. 2014;91(3):
25770.
Morabito A, Carrillio G, Daniele G, Piccirillo MC, Mon-
tanino A, Costanzo R, et al. reatment o small cell lung
cancer. Critical reviews in oncology/hematology Web site.
Accessed rom http://www.croh-online.com. 2014.
Pate P, enholder MF, Grif n JP, Eastridge CE, Weiman
DS. Preoperative assessment o the high-risk patient or
lung resection. he Annals o thoracic surgery. 1996;61:
1494500.
Silvestri GA, Gould MK, Margolis ML, anoue L , McCrory
D, oloza E, et al. Noninvasive staging o non-small cell
lung cancer: ACCP evidenced-based clinical practice guide-
lines (2nd edition). Chest. 2007;132:178S-201S.
T omas P, Rubinstein L. Cancer recurrence a er resection: 1
N0 non-small cell lung cancer. Lung Cancer Study Group.
T e Annals o thoracic surgery. 1990;49:2426; discussion
67.
Yan D, Cao C, DAmico A, Demmy L, He J, Hansen H,
et al. Video-assisted thoracoscopic surgery lobectomy at 20
years: A consensus statement. European journal o cardio-
thoracic surgery. Of cial journal o the European Associa-
tion or Cardio-thoracic Surgery. 2014;45:6339.
This page intentionally left blank
Abdo mina l Wa l l , Abdo men, a nd
Gast r o int est ina l Tr ac t
Robert B. Lim, Ronald A. Gagliano, Jr., and Richard Smith
This page intentionally left blank
 16
Abdominal Wall Reconstruction
erri L. Carlson
A 53-year-old emale presents to your clinic with
complaint o abdominal bulge and occasional dis-
com ort. She tells you that the bulge is worse when
she stands and causes pain throughout the day and
when she is active, and it seems to be getting bigger
over the past year. She has no obstructive symptoms
at this time. She has a history o a midline laparotomy
or trauma when she was younger. She had a ventral
hernia repair 6 years ago and thinks they put a syn-
thetic mesh in at that time. She had an episode o cel-
lulitis 1 year a er the hernia repair that was treated
with antibiotics. She has diabetes, which is controlled
by oral medications but is otherwise healthy. On exam
she has a large palpable de ect and on C scan she
has a 6 cm de ect in the midline containing omentum
and small bowel as well as two additional 1cm de ects
superior to the larger hernia without evidence o
obstruction.
1. What grade would this hernia be considered based
on T e Ventral Hernia Work Group (VHWG)
classif cation?
A. Grade 1
B. Grade 2
C. Grade 3
D. Grade 4
2. Regarding ventral hernia which o the ollowing is
correct?
A. Primary suture repair has the same recurrence
rate as does mesh repair.
B. T e type o suture used or closure o a midline
incision has been clearly de ned as a determi-
nant o postoperative hernia.
C. Secondary ventral hernias are thought to be
related to an abnormal ration o type I and III
collagen.
D. Ventral hernia repair is the most common proce-
dure per ormed by general surgeons.
3. O the ollowing positions o mesh placement
or hernia repairs, which has the highest rate o
recurrence?
A. Underlay repair
B. Onlay repair
C. Retro-rectus inlay repair
D. Interpositional repair
4. Regarding complications o hernia repair, which
o the ollowing is true?
A. Surgical site in ection rates range rom 0% to
12% or clean cases and up to 34% or clean-
contaminated and contaminated cases.
B. T e Centers or Disease Control (CDC) de nes
mesh in ections as occurring up to 6 months
a er implantation o prosthetic mesh.
C. Seroma ormation is common postoperatively
despite drain placement and there ore drains
should be removed within 1 to 2 weeks to prevent
retrograde in ection.
D. T e most common organisms identi ed in mesh
in ections are gram-negative organisms such as
Klebsiella and Proteus spp.
62 G EN ERAL S U RG ERY EXAM IN ATI O N AN D BO ARD REVIEW
5. Which o the ollowing is true with respect to
biologic and synthetic mesh materials?
A. Use o biologic mesh material in a contaminated
eld has around a 30% surgical site in ection rate.
B. Recurrence rates a er biologic mesh can be as
high as 30% in contaminated elds.
C. Advanced age is associated with an increased
risk o complications a er abdominal wall
reconstruction.
D. Synthetic mesh in ections have been success ully
treated using a vacuum-assisted closure (VAC)
technique without the need or mesh explantation.
3. D. Interpositional repair where the mesh is sutured
ANSWERS
1. C. A grading system was created to help identi y the
risk o morbidity rom a ventral hernia repair and
to help decide which type o mesh, biologic or syn-
thetic, would be best utilized. T is patient would be
considered a Grade 3 because o her history o previ-
ous in ection despite not requiring mesh removal. I
there was no previous in ection then she would be
considered a Grade 2.
Grade 1 (low risk) would mean no comorbidities
(i.e., a young healthy individual).
A Grade 2 (comorbid) consideration means
nding comorbidities (e.g., smoking, diabetes, or
malnutrition) that increase the risk o surgical site
in ections (SSIs). T ere was no evidence o wound
contamination or active in ection.
Grade 3 (potentially contaminated) shows evi-
dence o wound contamination (e.g., seroma, viola-
tion o the GI tract, or history o wound in ection).
T is includes patients with active or suspected
wound contamination.
Grade 4 (in ected) would be considered i active
in ections such as in ected synthetic mesh or a septic
dehiscence was ound.
2. C. It has long been established that direct suture
repair or ventral hernia has an unacceptably high
Re trore ctus pla ce me nt of me s h
recurrence rate with the exception o small 1 to 2 cm
primary hernias. T ere has been speculation that at the
time o primary operation the type o suture used or
closure correlates with rate o incisional hernia orma-
tion; however, there is no conclusive evidence to sup-
port this notion. Primary ventral hernias are thought
to have a genetic predisposition, while secondary or
incisional hernias are likely related to abnormal ratios
o ype I and III collagen as well as the amount o
metallopreotease expression. An average o 150,000 to
250,000 ventral hernias are per ormed each year mak-
ing it the h most common procedure.
directly to the ascial edge in a bridging ashion has
largely been abandoned due to the extremely high
recurrence rates. Onlay mesh repair places the mesh
above the rectus sheath. T ere are several types o inlay
repair. In the retrorectus repair, the mesh is placed
between the rectus abdominis muscle and the posterior
rectus sheath. Alternatively the mesh can be placed pre-
peritoneal between the posterior rectus sheath and the
preperitoneal at. An intraperitoneal or underlay type
repair places the mesh underneath the peritoneum. T is
type o repair is used or laparoscopic repairs. Because
the mesh is placed under the peritoneum, intraperito-
neal repair is thought to have higher rates o adhesions
and erosion o the mesh into the bowel. In general, the
type o repair is surgeon pre erence.
Advances in mesh products such as composite mesh
with anti-adhesive barriers have been developed to
decrease complications. Onlay type mesh repairs have
more potential or seroma ormation because a large
subcutaneous dissection is required and is also more
susceptible to contamination rom in ection because
o its super cial location. Inlay mesh repairs are gener-
ally pre erred because o their ability to distribute intra-
abdominal wall pressure and decrease overall tension.
Also underlay and retrorectus repairs have been shown
to have the lowest recurrence rates o all types o mesh
repair with the highest being interposition and onlay.
 C H AP TER 1 6 ABD O M IN AL WALL RECO N S TRU C TI O N
4. A. Surgical site in ections are common a er ventral
hernia repair and are de ned as super cial, deep, and
organ space in ections. Intraoperative level o wound
contamination based on CDC criteria include clean,
clean-contaminated, contaminated and dirty corre-
lates with rate o surgical site in ections. Clean cases
have an in ection rate o 0% to 12% while clean-
contaminated and contaminated have in ection rates
at high as 34%. T e CDC de nes mesh in ections as
occurring up to 1 year a er implantation o pros-
thetic mesh. T e most common organism cultured
rom in ected mesh is staphylococcus aureus and is
seen in up to 81% o cases. T is suggests a possible
skin f ora contamination at the time o mesh implan-
tation. While gram-negative organisms are presents
in mesh in ections, they only occur about 17% o
the time. Seromas are common a er ventral hernia
and drains are recommended to decrease the dead
space. While they can cause retrograde bacterial con-
tamination, there is no de nitive recommendation o
time or removal and are o en necessary or up to 4
to 6 weeks.
5. D. Prolonged operative time and American Society
o Anesthesiologists (ASA) > 2 have been associated
with major operative complications, but advanced
age has not been shown as a predictor o morbid-
ity. Particular comorbidities identi ed were obe-
sity, smoking, hypertension, diabetes and anemia.
Berrevoet et al. showed that use o vacuum-assisted
63
closure (VAC) techniques can be success ul in treat-
ing surgical site in ections, including synthetic mesh
in ections. A meta-analysis by Bellows et al. includ-
ing 60 studies showed a 17% surgical site in ection
and 15% recurrence rate in Grade 3 contaminated
elds a er biologic mesh repair.
BIBLIOGRAPHY
Albino FP, Patel KM, Nahabedian MY, Sosin M, Attinger CE,
Bhanot P. Does mesh location matter in abdominal wall
reconstruction? A systematic review o the literature and a
summary o recommendations. Plast Reconstr Surg. 2013;
132(5):12951304.
Bellows CF, Smith A, Malsbury J, Helton WS. Repair o
incisional hernias with biological prosthesis: a system-
atic review o current evidence. Am J Surg. 2013;205(1):
85101.
Butler CE, Baumann DP, Janis JE, Rosen MJ. Abdominal
wall reconstruction. Curr Probl Surg. 2013;50(12):557
86.
Fischer JP, Wink JD, Nelson JA, Kovach SJ 3rd. Among 1,706
cases o abdominal wall reconstruction, what actors inf u-
ence the occurrence o major operative complications?
Surgery. 2014;155(2):3119.
Lati R and Higa G. Surgery of complex abdominal wall defects.
New York, NY: Springer Science & Business Media. 2013;
5354.
Montgomery A. T e battle between biological and syn-
thetic meshes in ventral hernia repair. Hernia. 2013;17:
311.
urza KC and Butler CE. Adhesions and meshes: synthetic ver-
sus bioprosthetic. Plast Reconstr Surg. 2012;130(5 Suppl 2):
206S-13S.
 17
HerniaUmbilical/Ventral
with Cirrhosis
Richard M. Peterson

A 44-year-old male presents to the emergency depart- 2. Which o the ollowing actors is associated with
ment. He has had complaints o abdominal pain over increased incidence o abdominal wall hernias in
the last several days. oday he was bending over to pick patients with cirrhosis?
up something o o the oor and he elt a sudden sharp A. Increased clotting time
pain at his belly button. He states the area is now very B. Single episode o ascites ormation
tender and achy. He has elt some nausea or the last C. Rising creatinine
hour or two. No change in bowel habits prior to this D. Recanalized umbilical vein
episode. His past medical history is signi cant or an E. Decreased mobility
umbilical hernia, hypertension and cirrhosis. Past sur-
gical history is or an appendectomy when he was 27. 3. Which o the ollowing relates to worse outcomes
He smokes ppd and has 23 drinks per day. He denies in the setting o emergent repair o an umbilical
any drug use. When pressed he states that his doctors hernia in the cirrhotic patient?
told him his liver problems are because he drinks too A. Mesh insertion
much. B. Smoking
Vital signs are: HR 105, BP 140/91, RR 18, Pulse Ox C. Omentectomy
98% on RA. On exam there is no evidence o jaundice. He D. Small bowel resection
is noted to have tenderness directly at the umbilicus with E. Anemia
a protuberant abdomen. It is dull to percussion. T ere are
skin changes noted at the umbilicus, speci cally an area 4. Best management o an umbilical/ventral hernia in
o ulceration and a non-reducible hernia is noted. a patient with cirrhosis and ascites would include
Labs: which o the ollowing?
WBC: 13.1; Hgb/Hct: 13.5/40; Platelets: 202 A. Elective repair rather than emergent management
Na: 138; K: 3.7; BUN/Cr: 23/1.4; Bili: 1.7; INR: 1.6 B. Preoperative ascites control only
C. Postoperative ascites control only
1. Which o the ollowing negatively a ects the D. Primary repair o the hernia
patients perioperative mortality risk specif cally E. Intra-operative drain placement only
due to his cirrhosis?
A. White blood cell count o 13.1
B. Hypertension
C. Alcohol consumption
D. Smoking
E. INR
 C H AP TER 1 7 H ERn i A U m b i l i C Al / VEn TRAl w i TH C i RRH o s i s
ANSWERS
1. E. In a cirrhotic patient, the extent o the cirrhosis
a ects the perioperative mortality; but the etiology o
cirrhosis does not have to be taken into consideration.
o determine the patients 90-day mortality, the Model
or End Stage Liver Disease (MELD) score can be
used. T e MELD score is calculated by the equation:
MELD = 3.78 ln[serum bilirubin (mg/dL)] + 11.2
ln[INR] + 9.57 ln[serum creatinine
(mg/dL)] + 6.43
As such, the patients bilirubin, INR, and creati-
nine a ect his survival chances. T is system was
developed to determine outcomes or patients having
undergone transjugular intrahepatic portosystemic
shunt ( IPS) procedures. It has now become the
standard or determination o severity o liver dis-
ease (having replaced the Childs Classi cation) and
based on the new criteria as outlined by the United
Network or Organ Sharing (UNOS), requency o
dialysis was applied to the ormula. In addition the
etiology o the cirrhosis (or end-stage liver disease)
was not ound to be a signi cant prognostic indicator
and was removed rom the original MELD score. In
our particular patient the MELD score is 17, which
correlates with a 6% 3-month mortality.
MELD Scores
40 or more 71.3% mortality
3039 52.6% mortality
2029 19.6% mortality
1019 6.0% mortality
<9 1.9% mortality
2. D. Patients with liver cirrhosis and ascites have a risk
o developing an umbilical hernia that approaches
20%. A single episode o ascites is not highly asso-
ciated with abdominal wall hernia ormation. How-
ever as the number o episodes o ascites increases,
so does the incidence o hernia ormation, such that
by the third episode about 70% o patients will have
developed an umbilical hernia. T e other actors,
which include increased intra-abdominal pressure,
muscle wasting and weakening o the abdominal
ascia releated to malnutrition and recanalization
o the umbilical vein, are all contributing actors
to the development o umbilical hernias in the cir-
rhotic patient. T e decreased unctional status, rising
65
creatinine rom kidney dys unction, and the
increased platelet dys unction due to uremia do not
in uence the development o a hernia.
3. E. In the setting o emergent repair o abdominal
wall/umbilical hernia in the cirrhotic patient, pre-
operative anemia was the only preoperative predic-
tor o complicated outcome. T e other actors that
were ound to be statistically signi cant and related
to major complications were age greater than 65 and
higher Model or End Stage Liver Disease (MELD)
score. Additionally the authors in this study noted that
small bowel obstruction in this setting had a nine old
increase in risk or postoperative complications. How-
ever, smoking, omentectomy, mesh insertion and small
bowel resection were not ound to be signi cant actors
in the development o postoperative complications.
4. A. In a randomized controlled trial o 80 patients
having repair with or without mesh by Ammar, the
author ound that primary repair o an umbilical/
ventral hernia in the setting o cirrhosis and ascites
has a signi cantly higher recurrence rate than when a
mesh repair is per ormed (14.2% vs 2.7%, p < 0.05).
Most authors now advocate or more aggressive elec-
tive repair o hernias in patients with cirrhosis and
ascites even in the setting o Class B and C cirrhosis.
In the study by Carbonell et al they ound that elective
surgical morbidity in cirrhotics was no di erent rom
non-cirrhotics (15.6% vs. 13.5%; p = 0.18). Emergent
surgery morbidity was statistically signi cant between
the 2 groups (17.3% vs. 14.5%; p = 0.04). While di -
erences in elective surgical mortality in cirrhotics
approached signi cance (0.6% vs. 0.1%; p = 0.06),
mortality was 7- old higher in emergency surgery
(3.8% vs. 0.5%; p < 0.0001). In addition the oppor-
tunity to utilize laparoscopy in the elective setting in
this patient population has the ability to mitigate post-
operative complications and decrease length o hospi-
talization. Medical diuresis, postoperative paracentesis
and drain placement at time o surgery are all actors
that improve the postoperative course af er hernia
repair in these patients. Odom et al noted a signi cant
increase in major complications when no invasive
measure was used to control the ascites.
BIBLIOGRAPHY
Ammar SA. Management o complicated umbilical hernias
in cirrhotic patients using permanent mesh: randomized
clinical trial. Hernia. 2010;14(1):358.
66 G En ERAl s U RG ERY EXAm i n ATi o n An D b o ARD REVi Ew
Belli G, DAgostino A, Fantini C, et al. Laparoscopic incisional
and umbilical hernia repair in cirrhotic patients. Surg Lap-
arosc Endosc Percutan Tech. 2006;16:33033.
Carbonell AM, Wol e LG, DeMaria EJ. Poor outcomes in cir-
rhosis-associated hernia repair: a nationwide cohort study
o 32,033 patients. Hernia. 2005;9:3537.
Choi SB, Hong KD, Lee JS, et al. Management o umbilical
hernia complicated with liver cirrhosis: An advocate o
early and elective herniorrhaphy. Dig Liver Dis. 2011;43:
9915.
Eker HH, van Ramshorst GH, de Goede B, et al. Prospec-
tive study on elective umbilical hernia repair in patients
with liver cirrhosis and ascites. Surgery. 2011;150:
5426.
Kamath PS, Kim WR. T e model or end-stage liver disease
(MELD). Hepatology 2007;45(3):797805.
Odom SR, Gupta A, almor D, et al. Emergency hernia repair
in cirrhotic patients with ascites. J Trauma Acute Care Surg.
2013;75:4049.
Online MELD calculator: http://www.mayoclinic.org/medical-
pro essionals/model-end-stage-liver-disease/meld-model-
unos-modi cation
 18
Asymptomatic Inguinal Hernia
Lorenzo Anes-Bustillos
An otherwise healthy 31-year-old male presents with a
painless bulge in his right groin. Although it does not
bother him or limit his daily activities, he notices uc-
tuation in its size, rom being absent when he lies at or
a ew minutes, to a gol -ball sized mass upon coughing
or strenuous exercises. Physical examination con rms
the presence o a right inguinal hernia. No abnormalities
were noted on the contralateral side.
1. Regarding the management and indications or
surgical intervention o asymptomatic inguinal
hernias, which o the ollowing is correct?
A. Observation is not recommended, as the inci-
dence o inguinal hernia strangulation is greater
than 10% a er 5 years.
B. Elective surgical repair is advised or otherwise
healthy patients, as procedure is airly low-risk
and post-operative complications are always
minor, i any.
C. Both watch ul waiting and surgical repair are
sa e as treatment options, however most patients
will develop symptoms over time and require an
operation.
D. T e type o inguinal hernia, whether direct
or indirect, heavily dictates the management
approach, as incarceration is at least ten times
more o en in the case o direct hernias.
E. As emergency and elective inguinal hernia
repairs share similar morbidity and mortality
rates, watch ul waiting is always considered a
sa e option.
2. Which o the ollowing is considered the most
common early complication af er open inguinal
hernia repair?
A. Surgical site in ection
B. Hematoma/seroma
C. Urinary tract in ection
D. Small bowel obstruction
E. Recurrence
3. Which o the ollowing is true regarding laparo-
scopic inguinal hernia repair?
A. It is generally less expensive than the open repair.
B. Potential complications are similar, or less severe,
to those seen with open repair.
C. Procedure is limited to the repair o only one
de ect in the inguinal region given poor visual-
ization o the anatomy.
D. Although patients have a aster return to daily activ-
ities, they are associated with greater persistent pain
and numbness compared to the open approach.
E. It is usually the avored approach in special situ-
ations such as in recurrent or bilateral inguinal
hernias.
4. Af er an open inguinal hernia repair, which
symptom is likely to appear as a result o the most
commonly injured nerve in this type o approach?
A. Numbness on ipsilateral upper lateral thigh
B. Numbness on ipsilateral medial thigh
C. Hyper response o the cremasteric re ex
D. Hypersthesia o the ipsilateral hemiscrotum
E. Numbness o the suprapubic region
68 G EN ERAL S U RG ERY EXAM I N ATI O N AN D BO ARD REVI EW
5. Which o the ollowing is true regarding emoral
hernias?
A. Watch ul waiting or surgical repair are both rea-
sonable options to consider in otherwise healthy
patients diagnosed with asymptomatic emoral
hernia.
B. T e mesh plug repair is the pre erred approach
in emergent cases.
C. Rate o incarceration and strangulation is reported
as greater than 40%.
D. Men are more likely than women to experience
this type o hernia.
E. Its sac protrudes through the emoral canal,
bounded medially by the emoral vein.
ANSWERS
1. C. As one o the naturally weak points in the abdom-
inal wall, the groin area is prone to the protrusion
o peritoneal sac. When this occurs in the presence
o minor symptoms or in the absence o symptoms
altogether, the condition is known as asymptomatic
inguinal hernia. One-third o patients with inguinal
hernias all within this category, presenting with a
non-tender bulge in the area.
T e in erior epigastric vessels, as well as the inter-
nal and external inguinal rings, provide anatomic
landmarks that help in distinguishing direct and
indirect inguinal hernias. T e sac o a direct hernia
protrudes outward and orward, medial to the inter-
nal inguinal ring and the in erior epigastric vessels.
On the other hand, indirect hernias pass rom the
internal ring obliquely toward the external ring, lat-
eral to the vessels. A pantaloon-type hernia occurs
when both o these eatures are present. Regardless,
the anatomic distinction between these is o little
importance given the similarities in the approach
or operative repair. More traditional descriptions o
inguinal hernias are made on the basis o its contents
(e.g., sliding, Richters, Littres), or the status o the
contents (e.g., sliding, incarcerated, strangulated).
With more than 20 million operations per ormed
annually around the world, inguinal hernia repair is
the most common elective procedure per ormed in the
United States and Europe. T ere is a well-documented
debate as to what the best management is or asympto-
matic inguinal hernias, that being between the opera-
tive and the watch ul waiting approach. T e rationale
o repairing all inguinal hernias, whether symptomatic
or not, lies on their risk o incarceration and strangu-
lation. Elective repairs are considered relatively sa e
with low short-term morbidity, mortality, and recur-
rence rates. T is is di erent rom emergent operations,
which carry higher morbidity and mortality rates
given the additional risks o gangrene, per oration,
and in ection o the peritoneal cavity. Nonetheless,
watch ul waiting spares the patient rom the complica-
tions o elective surgery such as surgical site in ection,
hematoma, urinary retention, and more in the long-
term, chronic groin pain, neuralgia and recurrence.
Studies by Fitzgibbons et al. and ODwyer et al.
have been key in addressing the di erences between
elective surgery and watch ul waiting. Although
they both show no di erence in terms o discom ort
and pain across groups, there is a rate o conversion
driven mainly by pain o 54% and 72% a er 5 and 7.5
years, respectively, in those managed non-operatively.
A more recent systematic review o the evidence by
Mizrahi et al. (Arch Surg. 2012;147:27781) shows
that the rate o strangulation in those who do not
pursue surgery is quite low at less than 1% a er a two-
and a our-year ollow-up period. On the other hand,
the range o operative complications in those under-
going elective surgery goes rom 0% to 22.3%, with a
recurrence rate o 2.1%. Both treatment options are
thus considered sa e, although most patients will pro-
gress to develop symptoms and eventually require an
operation.
2. B. T e overall risk o complications ollowing open
inguinal hernia repair is low, and ortunately, these
are o entimes transient and easy to manage. Several
actors play a role in the occurrence o complications,
including the surgical technique, surgeon experience,
and anesthetic choices. Wound and scrotal hemato-
mas are amongst the most common early postopera-
tive complications, with reported rates o 6.1% and
4.5%, respectively. Neumayer L et al. compared open
mesh versus laparoscopic inguinal hernia repair and
reported a combined incidence o hematoma or ser-
oma o 13.6% in open cases, and 16.4% in those per-
ormed laparoscopically. Other less common adverse
events seen in the immediate postoperative period
include urinary retention, orchitis, pain, and urinary
tract and wound in ections. As or long-term com-
plications, chronic pain tops the list, with a reported
rate o 14% to 19% ollowing open repairs with some
series reporting requencies as low as 6% or as high as
75.5%. T e risk is lower ollowing laparoscopic cases,
with rates ranging between 9.8% to 13.8%. Orchitis,
in ection, and hernia recurrence are amongst other
common late complications.

3. E. T e approach and operative technique or the
repair o inguinal hernias has evolved throughout
the years. Repairs can be either done open or laparo-
scopically. T e open approach can be either a tissue
repair or a prosthetic (tension- ree) repair. Although
the ormer might be o historical interest, there are
some situations in which these may be indicated such
as in a contaminated eld, in pediatric patients, or
in those places where access to prostheses is limited.
By identi ying increased tension as the main cause
o recurrence, Lichtenstein popularized the use o a
synthetic mesh to bridge the hernia de ect and pro-
vide a tension- ree repair. T is approach is the gold
standard o open hernia repairs, as it has proven to
decrease the rates o postoperative discom ort, dura-
tion o hospital stay, and recurrence. T e laparoscopic
approach also o ers a tension- ree repair. T ose who
support this technique emphasize the quicker time to
recovery, less pain, better visualization o the anatomy,
and the ability to repair all the de ects in the inguinal
region. On the other hand, critics insist on the longer
operative times, technical challenges, risk o recur-
rence, and increased costs. A meta-analysis study by
Voyles et al. (Am J Surg. 2002;184:610) compared
the two approaches and showed that both provide
equivalent outcomes, with open repairs being lower
in cost, and entailing a lower risk o severe postopera-
tive complications. T ose unique to the laparoscopic
approach include small bowel obstruction, internal
hernia, bladder per oration, in arcted omentum, and
port-site hernia.
Exte rna l oblique
a pone uros is
Iliohypoga s tric n.
Re ctus a bdominus m.
Inte rna l oblique m.
a nd a pone uros is
P ubic tube rcle
Ing uinal anato my view,
o pe n appro ac h
C H AP TER 1 8 AS YM P TO MATIC I N G U IN AL H ERN I A 69
Special situations may avor the use o the lapa-
roscopic approach. In the setting o bilateral ingui-
nal hernias, the ability to use the same access sites
evidently translates into aster recovery and less
postoperative pain. However, whether done open or
laparoscopically, the simultaneous repair o bilateral
hernias does not increase the risk o re-operation or
recurrence. Another typical challenge or the surgeon
is that o recurrent hernias. T ese may be caused by
either technical problems (e.g., knot slipped, crushed
suture, inadequate bites o ascia), or patient ac-
tors such as malnutrition, steroid use, and smoking.
A second groin exploration entails cutting through
scar tissue that in itsel adds a certain degree o di -
culty and additional trauma with increased risk o
damage to the testicular blood supply and sensory
nerves. Access through virgin territories through a
posterior approach explains the advantage o laparo-
scopic repairs in these situations.
4. B. Depending on the approach used, speci c nerves
in the area will be more prone to injury. For example,
in open hernia repairs, the ilioinguinal nerve can be
most commonly injured at the external ring where it
runs on top o the cord. T is results in loss o the cre-
masteric re ex and numbness to the ipsilateral penis,
scrotum, and thigh. On the other hand, the posterior
approach used in laparoscopic surgery can result in
injuries to the lateral emoral cutaneous, emoral
branch o the genito emoral (sensory, upper lateral
thigh), and rarely, the emoral nerves. Hypersthesia
Ilioinguina l n.
Exte rna l s pe rma tic v.
Ge nita l bra nch of
ge nitofe mora l n.
70 G EN ERAL S U RG ERY EXAM I N ATI O N AN D BO ARD REVI EW
o the hemiscrotum and numbness o the suprapubic
region are not complications o nerve injury rom
inguinal hernia repairs.
5. C. Rate o incarceration and/or strangulation is
reported to be greater than 40%. Another potential
de ect where hernias can occur is that o the emoral
canal, bounded superiorly by the iliopubic tract, in e-
riorly by the lacunar ligament, laterally by the emoral
vein, and medially by the junction o the iliopubic tract
and lacunar ligament. Its dif cult diagnosis and treat-
ment pose a challenge to even the more experienced
surgeon. Added to this, a large proportion o patients
with this type o hernia present late to medical care,
o entimes requiring emergent interventions that
translate in higher risk o adverse postoperative events.
Women are more likely to experience this type o hernia
than men, comprising about 30% o their groin hernias
(versus only 2% in men). As they are usually associated
with incarceration and strangulation (reported rates
between 44% and 86%), the most adequate treatment
once diagnosed is surgery. All emoral hernias should
be repaired, and in the presence o incarcerated con-
tents, the sac should be assessed or viability. Delayed
diagnosis will lead to higher morbidity and mortality.
Di erent repair techniques are available and mainly
depend on the clinical presentation. Many consider the
mesh plug repair as the technique o choice in elective
and non-in ected cases. In contrast, the tissue repair
(i.e., McVay operation) should be pre erred in strangu-
lated cases in which severe in ection is present.
BIBLIOGRAPHY
Aasvang EK, Bay-Nielsen M, Kehlet H. Pain and unctional
impairment 6 years a er inguinal herniorrhaphy. Hernia.
2006;10:31621.
Alimoglu O, Alimoglu O, Kaya B, Okan I, et al. Femoral hernia:
a review o 83 cases. Hernia. 2006;10:703.
Amid PK, Shulman AG, Lichtenstein IL. Open tension- ree
repair o inguinal hernias: the Lichtenstein technique. Eur
J Surg. 1996;162:44753.
Bittner R, Schwarz J. Inguinal hernia repair: current surgical
techniques. Langenbecks Arch Surg. 2012;397:27182.
Chung L, Norrie J, ODwyer PJ. Long-term ollow-up o
patients with a painless inguinal hernia rom a random-
ized clinical trial. Br J Surg. 2011;98:5969.
Fitzgibbons RJ et al. Watch ul waiting vs repair o inguinal
hernia in minimally symptomatic men: a randomized clin-
ical trial. JAMA. 2006;295:28592.
Fitzgibbons RJ Jr, Ramanan B, Arya S, et al. Long-term results
o a randomized controlled trial o a nonoperative strategy
(watch ul waiting) or men with minimally symptomatic
inguinal hernias. Ann Surg. 2013;258:50815.
Hachisuka . Femoral hernia repair. Surg Clin North Am. 2003;
83:1189205.
Humes DJ, Radcli e RS, Camm C, and West J. Population-
based study o presentation and adverse outcomes a er
emoral hernia surgery. Br J Surg. 2013;100:182732.
Jones DB. Master echniques in Surgery: Hernia. Philadelphia,
PA: Lippincott Williams & Wilkins; 2012.
Kald A, Fridsten S, Nordin P, Nilsson E. Outcome o repair o
bilateral groin hernias: a prospective evaluation o 1,487
patients. Eur J Surg. 2002:168;1503.
Kingsnorth A, LeBlanc K. Hernias: Inguinal and incisional.
Lancet (London, England) 2003;362;156171.
Kurzer M, Belsham PA, Kark AE. Prospective study o open
preperitoneal mesh repair or recurrent inguinal hernia. Br
J Surg. 2002;89:903.
Lichtenstein IL, Shulman AG, Amid PK, Montllor MM. T e
tension- ree hernioplasty. Am J Surg. 1989;157(2):18893.
Malangoni MA, Rosen MJ. Hiatal Hernia and Gastroesopha-
geal Re ux Disease. In: ownsend CM, Beauchamp RD,
Evers BM, Mattox K, eds. Sabiston extbook of Surgery:
T e Biological Basis of Modern Surgical Practice. 19th ed.
Philadelphia, PA: Elsevier Saunders; 2012:11141140.
Matthews RD, Neumayer L. Inguinal hernia in the 21st century:
An evidence-based review. Curr Probl Surg. 2008;45:261312.
McCormack K, Scott NW, Go PM, Ross S, Grant AM. Lapa-
roscopic techniques versus open techniques or inguinal
hernia repair. Cochrane database Syst. Rev. CD001785
(2003). doi:10.1002/14651858.CD001785
Mizrahi H, Parker MC. Management o asymptomatic inguinal
hernia: A systematic review o the evidence. Arch Surg. 2012;
147:27781.
Naude GP, Ocon S, Bongard F. Femoral hernia: T e dire con-
sequences o a missed diagnosis. Am J Emerg Med. 1997;15:
6802.
Neumayer L, Giobbie-Hurder A, Jonasson O, et al. Open mesh
versus laparoscopic mesh repair o inguinal hernia. N Engl
J Med. 2004;350:181927.
ODwyer PJ, Norrie J, Alani A, Walker A, Du y F, Horgan P.
Observation or operation or patients with an asymptom-
atic inguinal hernia: a randomized clinical trial. Ann Surg.
2006;244:16773.
Page B, Paterson C, Young D, ODwyer PJ. Pain rom primary
inguinal hernia and the e ect o repair on pain. Br J Surg.
2002;89:13158.
Primatesta P, Goldacre MJ. Inguinal hernia repair: incidence
o elective and emergency surgery, readmission and mor-
tality. Int J Epidemiol. 1996;25:8359.
Sherman V, Macho JR, Brunicardi FC. Inguinal Hernias. In:
Brunicardi FC, Andersen D, Billiar , Dunn D, Hunter
J, Matthews J, et al, eds. Schwartzs Principles Surgery. 9e.
(pp 13051342) New York, NY: McGraw-Hill Pro essional;
2010: http://mhmedical.com/o content.aspx?aid=5031117
van den Heuvel B, Dwars BJ, Klassen DR, Bonjer HJ. Is surgi-
cal repair o an asymptomatic groin hernia appropriate? A
review. Hernia 2011;15:2519.
Voyles CR, Hamilton BJ, Johnson WD, Kano N. Meta-analysis o
laparoscopic inguinal hernia trials avors open hernia repair
with preperitoneal mesh prosthesis. Am J Surg. 2002;184:
610.
 19
Femoral Hernia
Harry T. Aubin
A 65-year-old emale is seen in your clinic or a lump
in her groin. She states the lump has been present or
a ew years and intermittently becomes larger in size.
On exam, there is no evidence o adenopathy or venous
thrombosis. A reducible hernia is palpated. You per-
orm an uncomplicated McVay repair and she is seen in
ollow up one year later with a recurrence.
1. Regarding emoral hernias, which o the ollowing
is true?
A. It is an acquired de ect.
B. It has a male preponderance.
C. It is more common than inguinal hernias.
D. T e incidence o incarceration is lower than
inguinal hernias.
2. Regarding the McVay technique or hernia repair,
which answer choice displays the key steps in order?
A. Expose Coopers ligament, suture transversus
abdominus aponeurosis to Coopers ligament
beginning at the pubic tubercle towards the
emoral sheath, place transition stitch containing
transversus abdominus, Coopers ligament, em-
oral sheath medial to emoral vein, and inguni-
nal ligament (iliopubic tract), approximate the
conjoint tendon to the inguinal ligament later-
ally to the internal ring.
B. Expose Coopers ligament, make relaxing inci-
sion on anterior rectus sheath, suture transver-
sus abdominus aponeurosis to Coopers ligament
beginning at the pubic tubercle towards the
emoral sheath, place transition stitch contain-
ing transversus abdominus, Coopers ligament,
emoral sheath medial to emoral vein, and
inguninal ligament (iliopubic tract), approxi-
mate the conjoint tendon to the inguinal liga-
ment laterally to the internal ring.
C. Expose Coopers ligament, make relaxing inci-
sion on anterior rectus sheath, suture transversus
abdominus aponeurosis to Coopers ligament
beginning at the pubic tubercle towards the em-
oral sheath laterally to the internal ring.
D. Expose Coopers ligament, suture transversus
abdominus aponeurosis to Coopers ligament
beginning at the pubic tubercle towards the em-
oral sheath laterally to the internal ring.
3. Regarding recurrence o this patients hernia,
which o the ollowing is the most likely etiology?
A. Congenital collagen disorder
B. Wound in ection
C. ension on suture line
D. Postmenopausal
4. Regarding repair o groin hernias, which o the
ollowing techniques will f x a emoral hernia?
A. Bassini repair
B. Marcy repair
C. Shouldice repair
D. Preperitoneal repair
E. Lichtenstein tension ree with mesh repair
ANSWERS
1. A. Femoral hernias are acquired hernias and NO o
congenital origin. T ey are more common in emales
72 G EN ERAL S U RG ERY EXAM IN ATI O N AN D BO ARD REVIEW
and more common in older women who are multip-
arous, as laxity o the abdominal wall and stretching
o the emoral ring with aging or pregnancy is elt
to be an etiology. Given the mostly xed, con ned
spaces o the emoral canal, these hernias are noto-
rious or incarcerating leading to emergent/urgent
hernia repair.
A study rom the Swedish Hernia Register showed
an incidence o 2 to 4 percent o all groin hernias over
a 14 year period. O these hernias, 35.9% o emoral
hernias were ound to present as an emergency (incar-
ceration) needing surgery, and o these, 22.7% required
bowel resection. T is is compared to only 4.9% need-
ing emergency surgery in the inguinal group. It is
seen more commonly in women, roughly 2:1 emale:
male.
2. B. T e McVay repair, aka the Coopers Ligament
repair, is a tissue repair that is e ective in repair o all
three groin hernias (indirect, direct, and emoral). It
is per ormed with non-absorbable sutures in an inter-
rupted ashion. Sutures are placed to sew the trans-
versus abdominus aponeurosis to Coopers ligament
beginning at the pubic tubercle towards the emo-
ral sheath. Once this is reached, place a transition
stitch containing transversus abdominus, Coopers
ligament, emoral sheath medial to emoral vein, and
inguinal ligament (iliopubic tract), then approximate
the transversus abdominal aponeurosis to the ingui-
nal ligament laterally to the internal ring. Exposure o
Coopers ligament is done prior to suturing. Addition-
ally, to avoid tension, a curvilinear relaxing incision
is made through the anterior rectus sheath starting
1cm cephalad o the pubic tubercle to near its lateral
border.
3. C. ension on the suture line is elt to be the most
common cause o hernia recurrence in general and
especially in tissue repairs. T is is why an adequate
relaxing incision is necessary in the McVay repair.
Most likely, there was some tension on the repair
despite the relaxing incision.
A shi has been made to tension ree repairs with
the usage o mesh. issue vs mesh repair was com-
pared in a large meta-anaylsis containing over 11,000
patients speci cally looking at recurrence rates a er
hernia surgery. Findings o this show the odds o
developing a recurrent hernia with mesh repairs were
reduced by about hal , though recurrence rates were
relatively small with each repair. Other actors can
contribute to recurrence such as wound in ection, but
are not the primary/most common cause. Congenital
collagen disorder is a rare disorder and is not likely to
be seen in this patient.
4. D. Lichtenstein tension ree hernia repair with mesh
is the most common hernia repair done at most
institutions. It requires little suturing, does not need a
relaxing incision, and does not need general anesthe-
sia. Un ortunately, the drawback o this repair is that
it does not close, nor cover, the emoral ring. T ere-
ore, it is not used or repair o emoral hernias.
T e Marcy repair only repairs the deep inguinal
ring and is mostly used in pediatric patients. T e
Bassini and Shouldice repairs only repair the ingui-
nal f oor and will not treat a emoral hernia.
T e preperitoneal repair, a variation known as the
Kugel repair, involves placing mesh in the preperito-
neal space and suturing this rom the pubic tubercle
to Coopers ligament. Bi-layer mesh repair, in theory
is a combined preperitoneal and Lichtenstein repair
with mesh and is used or emoral hernia repair. Plug
and patch repair can be utilized to obliterate the
emoral canal in emoral hernia repair. Laparoscopic
repair, as with the above repairs, is a described tech-
nique or repair o emoral hernias and utilizes the
preperitoneal space.
BIBLIOGRAPHY
Dahlstrand U, Wollert S, Nordin P, Sandblom G, Gunnarsson U.
Emergency emoral hernia repair: A study based on a
national register. Ann Surg 2009;249(4):6726.
EU Hernia rialists Collaboration. Repair o groin hernia
with synthetic mesh: Meta-analysis o randomized con-
trolled trials. Ann Surg 2002;235(3):32232.
Kark AE, Kurzer M. Groin hernias in women. Hernia. June
2008;12(3):26770.
McVAY CB, CHAPP JD. Inguinal and emoral hernioplasty:
T e evaluation o a basic concept. Ann Surg. 1958;148(4):
499510; discussion 510-2.
Malagoni MA, Rosen MJ. Hernias. In: ownsend CM, Beau-
champ RD, Evers BM, Mattox K, eds. Sabiston extbook of
Surgery: T e Biological Basis of Modern Surgical Practice.
19th ed. Philadelphia, PA: Elsevier Saunders; 2012:1114
40.
 20
Inguinal Neuralgia
Harry T. Aubin and Eric Balent
A 35-year-old male presents to clinic three months a er
an uncomplicated open right inguinal hernia repair with
mesh or a chronic, minimally symptomatic, indirect
inguinal hernia. During the operation, the ilioinguinal
nerve was intentionally divided. He reports continued
right sided, sharp, episodic groin pain radiating to his
testicle that is worse than the symptoms he had prior
to repair. He took ibupro en and acetaminophen or
6 weeks a er the surgery with minimal relie . T e pain
is beginning to limit his activities at work. He now com-
plains o worsening pain.
1. Regarding the pathophysiology o chronic groin
pain af er hernia surgery, which o the ollowing is
correct?
A. Most commonly, it is elt to be neuropathic and
due to primary nerve injury during the operation.
B. It is elt to be due to in ammatory mechanisms
rom the operation and healing.
C. It is nociceptive.
D. acking mesh to nerves in a laparoscopic repair
is an uncommon cause.
E. Secondary nerve injury rom either in amma-
tion or nerve degeneration rom mesh contact is
the most common cause.
2. Regarding the management o chronic groin pain
af er hernia surgery, which o the ollowing is
correct?
A. Imaging studies (ultrasound, C scan, and/or
MRI) are suggested to rule out underlying causes.
B. Peripheral nerve block should be attempted to
con rm diagnosis.
http://surgerybook.net/
C. Re erral to a pain management specialist is
recommended.
D. riple neurectomy is recommended only a er
ailing less invasive treatments by a pain man-
agement specialist.
E. All are correct.
3. Regarding nerve injuries in hernia repair, which o
the ollowing is correct?
A. Injury to the ilioinguinal nerve causes loss o
cremasteric re ex, and numbness to the ipsilat-
eral scrotum, penis, and medial thigh.
B. Injury to the emoral branch o the lateral emo-
ral cutaneous nerve causes loss o sensation to
the medial thigh.
C. ack placement in erior to the iliopubic tract and
medial to the spermatic cord is avoided to mini-
mize nerve damage in laparoscopic hernia repair.
D. Injury to the genital branch o the genito emo-
ral nerve results in loss o sensation o the entire
scrotum and lack o cremestric re ex on the con-
tralateral side.
4. Regarding surgical management o post-
herniorrhaphy neuralgia, which o the ollowing is
correct?
A. ailored neurectomy is more ef ective than triple
neurectomy at decreasing symptoms postopera-
tively.
B. riple neurectomy is ef ective at eliminating pain
in upwards o 80% o patients, making this the
most ef ective surgical therapy.
74 G EN ERAL S U RG ERY EXAM I N ATI O N AN D BO ARD REVI EW
C. Mesh explantation alone is an e ective strategy
and has been shown to be superior to neurec-
tomy with or without mesh explantation.
D. Patients with pre-existing pain hyper-sensitiza-
tion are ideal candidates or neurectomy.
5. Regarding intentional division of the ilioinguinal
nerve at time of initial herniorrhaphy, which of the
following is correct?
A. T ere is no di erence in sensory loss between
division and preservation o the nerve.
B. A signi cant decrease in postoperative chronic
pain is seen when the ilioinguinal nerve is inten-
tionally divided during initial surgery.
C. T ere is no signi cant di erence in decreasing
chronic postoperative groin pain.
D. T ere is less debilitating pain with routine divi-
sion o the ilioinguinal nerve.
E. T ere is less pain i the nerve is clipped versus
being divided by electrocautery.
ANSWERS
1. A. Chronic postoperative groin pain is elt to
be secondary to neuropathic pain rom aberrant
nerve conduction as a result o either primary or
secondary nerve injury. ypically, it is ongoing
pain, which is di icult to manage. Initial postoper-
ative pain is due to in lammatory cytokine release
and nociceptive mechanisms. Nocioceptive pain is
pain elt via neural pathways in which tissue dam-
age surrounding the nerves is the stimulus. his
type o pain typically resolves over 6 weeks and
is amendable to anti-in lammatory medications
such as NSAIDS.
Primary nerve injury is de ned as direct nerve
injury and can occur during hernia repair in mul-
tiple ways. During dissection, complete or partial
nerve transection can occur later orming a neu-
roma. Additionally, handling o the nerve can result
in crushing, stretching or burns rom cautery. Most
commonly, the nerve is incidentally entrapped with
mesh, suture and/or staple.
Secondary nerve injury is de ned as nerve degen-
eration/demyelination rom an in ammatory pro-
cess. It is not as common as primary nerve injury
in the pathogenesis o postherniorrhaphy neuralgia.
Secondary nerve injury is elt to be rom meshoma,
excessive scar tissue or contact with mesh not involving
entrapment.
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2. E. Chronic groin pain, or chronic posthernior-
rhaphy inguinal pain, a er hernia surgery is diag-
nosed by chronic pain at site or region o prior
hernia repair that persists postoperatively or over
three months that cannot be attributed to another
cause. T e prevalence o postoperative chronic groin
pain varies rom study to study. A large Swedish sur-
vey including 2500 patients, noted 14% o patients
had li estyle limiting groin pain, and 30% chronic
pain that didn't hinder their li estyle. A smaller
series noted 1.5% o patients had moderate to severe
pain at ve years. Interestingly, it is more common
in younger patients, with persistent pain in 58% o
patients under the age o 40 and only 14% o those
older than age 40.
Upon presentation o a patient you suspect has
chronic postoperative groin pain, anti-in ammatory
treatment should be attempted but usually has little
e ect on neuropathic pain. In this instance, an ilioin-
guinal nerve block can help con rm diagnosis and is
indicated. Additionally, nerve ablation with phenol or
radio requency ablation is used. Patients who ail less
invasive means o treatment should undergo triple
neurectomy.
Non-neuropathic pain must be excluded. T is
is done with history, physical, and imaging studies.
T e ideal imaging study has not been determined by
randomized trials. In general, ultrasound is the least
expensive test with minimal risk to the patient. How-
ever, C and MRI can provide a better representation
o the location o mesh, location o neuronal struc-
tures, and presence o recurrent hernias.
3. A. An injury to the emoral branch o the lateral em-
oral cutaneous nerve causes lack o sensation to the
lateral thigh and not the medial thigh as mentioned
in the answer. T is nerve is seen in laparoscopic
hernia repairs and is not encountered during open
inguinal hernia repair. Other nerves encountered
laparoscopically include the lateral emoral cutane-
ous nerve, the ilioinguinal nerve lateral to the inter-
nal ring, the iliohypogastric (which cannot be seen
but could be injured with mesh xation), the genital
branch o the genito emoral nerve, and the emoral
nerve. T e so called triangle o pain is de ned as the
iliopubic tract superiolaterally, the spermatic vessels
posteriomedially, and the re ected peritoneal edge
laterally. T is contains the genito emoral nerve and
the lateral emoral cutaneous nerve. Minimization o
nerve injuries laparoscopically is achieved by avoiding

tack placement in erior to the iliopubic tract later-
ally beyond the external iliac artery.
For open inguinal hernia repairs, the ilioinguinal
nerve is the most common cause o pain. Injury to
this nerve can also cause ipsilateral scrotal, thigh,
and penis numbness as well as loss o the cremasteric
re ex. Injury to the genital branch o the genito emo-
ral nerve can less commonly cause pain. More com-
monly, scrotal sensation and lack o cremasteric
re ex on the ipsilateral side are seen.
He s s e lba chs tria ngle
Re ctus m.
Dire ct inguina l
he rnia
P ubic tube rcle
Fe mora l he rnia
Va s de fe re ns
Tria ngle of doom
Ilia c ve s s e ls
Ing uinal anato my vie w,
pre -pe rito ne al appro ac h
at 225 patients. O these, 80% reported resolution
o pain, 15% had transient pain, and only 2 patients
reported no improvement.
ailored neurectomy could be bene cial as it is
less morbid, leaving the patient with less sensory loss.
Although tailored neurectomy has not been com-
pared to triple neurectomy, and only been studied in
small studies, it was ound to provide complete pain
relie in only 54% o patients, giving partial relie
in 24% o patients and leaving 24% with no bene t.
Mesh explantation alone is not likely to be an
e ective strategy or the treatment o chronic post-
herniorraphy neuralia unless secondary nerve injury
either by excessive scar ormation over the mesh
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C H AP TER 2 0 IN G U I N AL N EU RALG IA 75
4. B. Given the signi cant morbidity and dif culty o
the operation, neurectomy is reserved or patients
who ail pain management strategies. Patients with
pre-existing pain syndromes or hyper-sensitization
are not ideal surgical candidates. O the operative
strategies, triple neurectomy o the ilioinguinal, ili-
ohypogastric and genital branch o the genito emo-
ral nerve has been shown to be the best at a surgical
cure. T ere have been a ew small trials studying suc-
cess rates or triple neurectomy, the largest looking
Epiga s tric ve s s e ls
Indire ct inguina l he rnia
Inguina l liga me nt
Tria ngle of pa in
Te s ticula r
ve s s e ls
or nerve contact with the mesh not associated with
entrapment, or meshoma by imaging is suspected. No
randomized controlled trials have compared triple
neurectomy with and without mesh explantation; but
i mesh removal alone does not relieve the pain then
proceeding with a third operation in the inguinal
region may result it a very dif cult dissection, inabil-
ity to identi y all 3 nerves, and worsening pain.
5. C. Intentional ilioinguinal nerve division dur-
ing herniorrhaphy has been postulated to decrease
chronic groin pain. Its bene ts have been studied in
multiple randomized control trials. It is clear that
operative division will decrease sensation along the
76 G EN ERAL S U RG ERY EXAM IN ATIO N AN D BO ARD REVI EW
distribution o the nerve (the groin and hemiscro-
tum). However, no statistically signi cant advan-
tage at decreasing post-herniorrhaphy neuralgia at
1month, 6 month, and 1 year ollow ups has been
shown in large studies and meta-analysis o over
1200 patients.
BIBLIOGRAPHY
Amid PK. Causes, prevention, and surgical treatment o
postherniorrhaphy neuropathic inguinodynia triple neu-
rectomy with proximal end implantation. Hernia. 2004;
Dec; 8(4):3439.
Bjurstrom MF, Nicol AL, Amid PK, Chen DC. Pain control
ollowing inguinal herniorrhaphy: Current perspectives.
Jour of Pain Research. 2014;7:27790.
Franneby U, Sandblom G, Nordin P, Nyren O, Gunnarsson U.
Risk actors or long-term pain a er hernia surgery. Ann
Surg. 2006;244:212.
Hsu W, Chen CS, Lee HC, Liang HH, Kuo LJ, Wei PL, am
KW. Preservation versus division o ilioinguinal nerve on
open mesh repair o inguinal hernia: A meta-analysis o
http://surgerybook.net/
randomized controlled trials. World J Surg. October 2012;
36(10):23119.
Hakeem A, Shanmugam V. Current trends in diagnosis and
management o post-herniorraphy chronic groin pain.
World J Gast Surg. 2011;3:73.
Kehlet H, Jensen S, Wool CJ. Persistent postsurgical pain:
Risk actors and prevention. Lancet 2006; 367:1618.
Malangoni MA, Gagliani RJ. Hernias. In: ownsend CM,
Beauchamp RD, Evers BM, Mattox K, eds. Sabiston ext-
book of Surgery: T e Biological Basis of Modern Surgical
Practice. 19th ed. Philadelphia, PA: Elsevier Saunders;
2012:111440.
Picchio M, Palimento D, Attanasio U, Matarazzo PF, Bambini
C, Caliendo A. Randomized controlled trial o preservation
or elective division o ilioinguinal nerve on open inguinal
hernia repair with polypropylene mesh. Arch Surg. July
2004;139(7):7558.
Poobalan AS, Bruce J, King PM, Chambers WA, Krukowski
ZH, Smith WC. Chronic pain and quality o li e ollowing
open inguinal hernia repair. Br J Surg. 2001;88:1122.
Reinpold WM, Nehis J, Eggert A. Nerve management and
chronic pain a er open inguinal hernia repair: A prospec-
tive two phase study. Ann Surg. 2011;254:163.
 21
Hiatal and Paraesophageal Hernia

Steven M. Henriques

A 63-year-old emale presents with a history o gastroe- 5. T e patient undergoes an uneventful diaphragm
sophageal re ux disease (GERD). She takes a PPI twice repair and a Nissen fundoplication. wo years post-
daily and complains o having more regurgitation over operatively the patient presents with a recurrence
the past 6 months. She has a history or diabetes mel- of her symptoms. On evaluation, it is noted that
litus and hypertension. She has no history o alcohol the Nissen fundoplication is slipped. What is an
or tobacco use. She is otherwise in good health with no alternative for repair?
other problems. Her BMI is 38 kg/m 2. A. Colles gastroplasty
B. Roux-En-Y gastric bypass
1. What is the most likely cause of her symptoms?
C. Ivor-Lewis esophagectomy
A. Gastroparesis D. Esophagomyotomy
B. Esophageal cancer
C. Gastric ulcers
D. Hiatal hernia ANSWERS
E. Obesity 1. D. Hiatal hernia is quite common in the population
with up to 60% o the population having such hernias.
2. What should be the next appropriate test?
Approximately 9% are symptomatic. Regurgitation
A. CXR can be the only symptom but at times some will have
B. Manometry cardiac and pulmonary symptoms. Esophageal cancer
C. pH monitoring must be on the di eretial diagnosis with anyone pre-
D. Endoscopy senting with regurgitation and a history o GERD. It
is unlikely to be cancer as the patient has not had any
3. What is the most common type of hiatal hernia?
dysphagia or weight loss. Gastric ulcers are associated
A. ype I with GERD but will usually present with abdominal
B. ype II pain. Diabetic neuropathy can a ect the intestinal
C. ype III tract and can cause gastroparesis. Patients with this
D. ype IV condition can have regurgitation, abdominal ullness,
and pain. T is patient has no other symptoms con-
4. Regarding the etiology of hiatal hernias most are?
sistent with diabetic periperal neuropathy. Obesity is
A. Congenitally acquired a risk actor to re ux disease but the most common
B. Have no amilial hereditary pattern cause in this patient is likely a hiatal hernia.
C. Similar to a Bochdalek hernia
D. Result rom a weakening o the phrenoesopha- 2. D. T e workup has to exclude other pathologies.
geal ligament Endoscopy is essential to the evaluation o patients

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78 G EN ERAL S U RG ERY EXAM IN ATIO N AN D BO ARD REVI EW
presenting with GERD, to deteremine the extent o
esophagitis, and to determine the extent o a hiatal
hernia, to rule out maligancy. Manometry can be used
to evaluate the LES and look or motility disorders.
pH monitoring is the gold standard or diagnosing
and quanti ying acid re ux. Impedance pH can also
be per ormed to discern the di erence between non-
acid and acidic re ux. Additionally, the use o either
C or a swallow study can be used or evaluation o
the motility o the stomach and can help decipher i
there is a need or pyloroplasty or pyloromyotomy.
3. A. ype I (sliding) hernia: Upward herniation
o the cardia in the posterior mediastinum, the GE
junction migrates above the diaphragm. ype I hiatal
hernias are the most common at 90%.
ype II (paraesophageal) hernia: T e GE junc-
tion remains in the normal anatomical position, the
undus herniates through the hiatus.
ype III (mixed) hernia: Characterized by an
upward herniation o both the cardia and the gastric
undus.
ype IV hiatal hernia: An additional organ, usu-
ally the colon but could involve the spleen or liver,
herniates as well.
4. D. Cephalad migration o the gastroesophageal junc-
tion may result rom weakening o the phrenoesoph-
ageal ligament. Depletion o elastin f bers leads to
stretching o the ligament and proximal displacement
http://surgerybook.net/
o the gastroesophageal junction. Most cases o hiatal
hernia are acquired rather than congenital. A small
number o cases o amilial hiatal hernias have been
shown. Bochdalek hernias are congenital hernias
involving the right posterior diaphragm usually
ound in children, it is extremely rare to f nd in the
adult population with less than 100 published cases.
5. B. A good alternative or ailed undoplications is a
Roux-En-Y Gastric Bypass. Kim et al. showed that
at 11 months, 93.3% o patients were symptom- ree.
Colles Gastroplasty is used as a lengthening proce-
dure and has no role in the management o revision
on its own. Esophagectomy has no role in the revi-
sion o slipped undoplication. Esophagomyotmy is
used to treat achalasia to release the pressure on the
LES. A slipped Nissen re ers to the stomach that slips
under the wrap creating an hourglass shape de orm-
ity that can be seen on UGI. T is is di erent rom a
recurrence where the stomach re-herniates into the
chest.
BIBLIOGRAPHY
Alam U, Asghar O, Malik RA. Diabetic gastroparesis: thera-
peutic options. Diabetes T er. August 2010;1(1):3243.
Baglaj SM, Noblett HR. Paraoesophageal hernia in children:
amilial occurrence and review o the literature. Pediatr
Surg Int. 1999;15:8587.
Curci JA, Melman LM, T ompson RW, Soper NJ, Matthews BD.
Elastic f ber depletion in the supporting ligaments o the
gastroesophageal junction: a structural basis or the devel-
opment o hiatal hernia. J Am Coll Surg. 2008;207:1916.
Kim M, Navarro F, Eruchalu CN, Augenstein VA, Heni ord B ,
Ste anidis D. Minimally invasive Roux-en-Y gastric bypass
or undoplication ailure o ers excellent gastroesophageal
re ux control. Am Surg. July 2014;80(7):696703.
Kohn GP, Price RR, DeMeester SR, Zehetner J, Muensterer
OJ, Awad Z, et al. Guidelines or the management o hiatal
hernia. SAGES Guidelines Committee. Surg Endosc.
December 2013;27(12):440928.
Maish MS. Esophagus. In: ownsend CM, Beauchamp RD,
Evers BM, Mattox K, eds. Sabiston extbook of Surgery:
T e Biological Basis of Modern Surgical Practice. 19th ed.
Philadelphia, PA: Elsevier Saunders; 2012:10121066.
Patti MG, Fisichella PM, Perretta S, et al. Impact o minimally
invasive surgery on the treatment o esophageal achalasia:
a decade o change. J Am Coll Surg. 2003;196:698705.
Petersen RP, Pellegrani CA, Oelschlager BK. Hiatal hernia
and gastroesophageal re ux disease. In: ownsend CM,
Beauchamp RD, Evers BM, Mattox K, eds. Sabiston extbook
of Surgery: T e Biological Basis of Modern Surgical Practice.
19th ed. Philadelphia, PA: Elsevier Saunders; 2012:106786.
Salstio R, Nabais C, Paredes B, Sousa FV, Porto E, Fradique C.
Association o intestinal malrotation and Bochdalek hernia
in an adult: a case report. BMC Res Notes. May 2014;13;7:296.
 22
Achalasia

Mary . ODonnell and E. Matthew Ritter

A 42-year-old male or whom you recently per ormed a

success ul inguinal hernia repair, presents to your clinic
with a chie complaint o increasing di culty swallow-
ing some solids and occasionally liquids. He reports
this has been worsening or the last 5 months. He has
been treated by his primary care physician with daily
omeprazole, but this does not seem to be improving his
symptoms. Since you did such a good job in repairing
his hernia, he is now coming to you or advice on this
problem. He appears healthy, his vital signs are normal,
and he is maintaining his normal weight.

1. T e most appropriate initial study to help you sort

through the di erential diagnosis o this patients
dysphagia is?
A. Contrast esophagram
B. Esophageal manometry
C. Esophagogastroduodenoscopy
D. H. pylori testing
E. Chest X-ray 3. Upper endoscopy reveals no evidence o
esophagitis, but some ood is present in the distal
2. A contrast esophagram image is shown to the right. esophagus. Manometry shows aperistalsis and a
What additional study or studies should be ordered non-relaxing LES. Which initial treatment o ers
next in the diagnostic workup o this patient? the patient the best chance o long term-relie ?
A. Esophageal manometry A. Pneumatic dilation o the LES
B. Esophagogastroduodenoscopy (EGD) B. Calcium channel blocker therapy
C. 24-hour pH monitoring C. Esophageal myotomy with undoplication
D. 24-hour pH monitoring and EGD D. Botulinum toxin injection at LES
E. Esophageal manometry and EGD E. Esophagectomy

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80 G EN ERAL S U RG ERY EXAM IN ATIO N AN D BO ARD REVI EW
4. Suppose in this same patient, that the results o
the manometry do not show achalasia. Instead,
the standard esophageal manometry shows 10/10
normal propagated swallows with a mean distal
esophageal amplitude pressure o 293 mm Hg. T e
lower esophageal sphincter pressure is normal and
relaxes completely. T e results o ambulatory pH
monitoring and EGD were both normal. What is
the most likely diagnosis?
A. Achalasia
B. Pseudoachalsia
C. Di use esophageal spasm
D. Nutcracker esophagus
ANSWERS
1. A. Contrast esophagram o ers the most use ul
in ormation in initially sorting through this di er-
ential. T e esophagram shown essentially eliminates
diverticula and a hiatal hernia.
2. B. T is esophagram would typically be ollowed
up with an EGD. While the esophagram shown
makes the diagnosis o a diveritcula or an hiatal
hernia less likely, there are still several diagno-
ses that are not ruled out or con rmed. An EGD
would be needed to exclude anatomical causes or
dysphagia, such as neoplasm or stricture. T e EGD
would also be used to document any evidence o
re ux or eosinophilic esophagitis. I there is no
re ux seen on EGD, a 24-hour pH study could
con rm the presence o unctional re ux disease.
I the 24-hour pH study is normal, then a manom-
etry study could be done to rule out motility dis-
orders like achalasia, di use esophageal spasm,
connective tissue disorders, and nutcracker esoph-
agus. Even i the 24-hour pH study is con rma-
tory, though, an esophageal manometry should be
done to rule out a concominant underlying motil-
ity disorder. By skipping the EGD and proceeding
directly to manometry, a diagnosis, such as pseu-
doachalasia secondary to a distal anatomic partial
obstruction, may be missed.
Di erential Diagnosis Conf rmatory est
Neoplasm Esophagram
Diverticulae
Hiatal Hernia
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Di erential Diagnosis Conf rmatory est
Neoplasm EGD
Eosinophilic Esophagitis
GERD
Schatzskis Ring/Stricture
Esophageal Ulcer
ypical Re ux 24 hr pH monitoring
Atypical Re ux
Achalasia Manometry
DES
Nutcracker Esophagus
Connective issue Disorder
3. C. T is patient has achalasia. In the absence o an
obstructing entity (neoplasm, hiatal hernia, diverticuli)
retained ood in the esophagus is suspicious or acha-
lasia. T e diagnosis is con rmed by manometry. In
patients with achalasia, the manometry demonstrates
an esophagus in which there is complete absence o
peristalsis and an LES pressure that is normal to mod-
erately elevated, but ails to completely relax. Although
a hypertensive LES and an LES that ails to completely
relax are of en associated with achalasia, only the
complete absence o peristalsis is required or the
diagnosis. T e pathophysiology o achalasia is loss o
ganglion cells in the myenteric plexus and interrup-
tion o inhibitory vagal nerve innervation.
T e treatment or achalasia requires relaxing the
hypertensive smooth muscles o the LES. In general,
that can be done surgically by dividing the muscles
o the LES, injecting botulinum toxin endoscopi-
cally, or dialating the LES using a balloon. T is is also
done endoscopically. Surgical treatment with myot-
omy provides long-term treatment o achalasia with
a high success rate. Calcium channel blockers have
shown inconsistent success and do not have a role in
achalasia treatment. Botulinum toxin usually requires
repeated interventions every 6 to 12 months, as does
dilation. Both eventually become less e ective. T ese
may be good options in persons who are poor opera-
tive risks or in those who do not want surgery.
Esophagectomy would be required in the setting
o cancer and is indicated as a last resort i multi-
ple myotomies ail. T e POEM or per oral endo-
scopic myotomy technique involves dividing the LES
muscle endoscopically. T is has the advantage o

avoiding most surgical risks. T e long-term success
rate, though, is unknown and is not yet considered
the equivalent o a surgical myotomy.
4. D. Manometry is used to rule out esophagility motil-
ity disorders. Not only does it measure how well ood
travels down the esophagus into the stomach, it also
measures the pressure inside the esophagus and the
LES. T e normal pressure o an LES is 10 to 15 mm
Hg. Patients with GERD will of en have a hypoten-
sive LES with a pressure o around 5 to 8 mm Hg and
normal to moderately abnormal peristalsis. T e low
LES pressure is thought to allow gastric contents to
re ux back into the esophagus.
wenty- our-hour ambulatory manometry can
be used to diagnose spastic disorders such as Di use
Esophageal Spasm (DES), nutcracker esophagus, or
hypercontractile esophageal motility disorder is a rare
cause o dysphagia. T e nutcracker esophagus is char-
acterized by very high LES pressures (> 50 mm Hg)
during swallowing with otherwise normal peristalsis.
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C H AP TER 2 2 AC H ALAS I A 81
DES would be characterized by high pressures through-
out the esophagus (2550 mm Hg) and poor peristalsis.
Psuedoachalasia would show a slightly hypertensive but
relaxing LES and abnormal but not absent peristalsis.
Connective tissue disorders, like scleroderma, would be
hallmarked by poor peristalsis and a normal LES.
BIBLIOGRPAHY
Castell, Donald O. Linda Diederich, June A. Castell. Esophageal
Motility and pH esting, echnique and Interpretation, 3rd
edition. Highlands Ranch, CO: Sandhill Scienti c, Inc.; 2000.
Guidelines or the Surgical reatment o Esophageal Achalasia.
Society o American Gastrointestinal and Endoscopic Sur-
geons (SAGES) Web site. Available rom http://www.sages.
org/publications/guidelines/guidelines- or-the-surgical-
treatment-o -esophageal-achalasia/ Published May 2011.
Accessed June 2014.
Ste anidis, D. et al. Guidelines for the Surgical reatment of
Esophageal Achalasia, Society o American Gastrointesti-
nal and Endoscopic Surgeons (SAGES), May 2011.
utuian R, Castell DO. Review article: esophageal spasm
diagnosis and management. Aliment Pharmacol T er. 2006;
23(10):13931402.
 23
Gastric Cancer

Brian J. Pottor and Farah A. Husain

A 68-year-old male with a history o hypertension and D. Diagnostic laparoscopy

hypercholesterolemia presents to his primary care phy- E. riple-phase helical computed tomography (C )
sicians o ce with a chie complaint o worsening epi- scan
gastric pain and weakness. T e pain is improved with
oral intake, especially milk-based products. T e patient 3. T e EUS suggests a 3N0 lesion. T e most appro-
has been treating his pain with naproxen. In the o ce, priate next step would be:
the patient is non-toxic with normal vital signs. His A. Neoadjuvant therapy
physical examination reveals mild epigastric tenderness B. Proximal gastrectomy with negative margins
with deep palpation. Serum hemoglobin was 8.3 g/dL. (R0) only
Fecal occult blood testing was positive. T e patient C. otal gastrectomy
underwent colonoscopy, which was normal. Esophago- D. otal gastrectomy with splenectomy and distal
gastroduodenoscopy (EGD) revealed a 2.5 cm ulcerated pancreatectomy
lesion with elevated, irregular borders 5 cm distal to the E. Esophagogastrectomy with colonic interposition
gastroesophageal junction. gra

1. Appropriate management o the ulcer includes? 4. T e f nal pathology revealed a 4N1 lesion with
A. Observation negative margins. T e patient should next receive:
B. Cessation o naproxen and begin sucral ate and A. No additional therapy
a proton-pump inhibitor with repeat EGD in B. Imatinib
3 months C. External-beam radiation only
C. Biopsy the ulcer D. Fluorouracil-based chemotherapy only
D. Proximal gastrectomy E. External-beam radiation and uorouracil-based
E. otal gastrectomy chemotherapy

2. Final pathology reveals a poorly di erentiated
adenocarcinoma. T e most sensitive preoperative
examination to determine and N stage is:
A. Positron emission tomography (PE ) scan
B. Endoscopic ultrasound (EUS)
C. Magnetic resonance imaging (MRI) with gado-
linium
5. Which o the ollowing describes the association
between Irishs node and gastric cancer?
A. An anterior mass palpable on digital rectal
examination
B. A metastatic le supraclavicular lymph node
C. An ovarian mass rom metastatic tumor
D. Metastatic le axillary lymph node
E. Umbilical mass suggestive o metastatic gastric
cancer

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ANSWERS
1. C. Historically, biopsy o gastric ulcers was uni orm
practice throughout medical and surgical disciplines
since there was a 5% to 11% attendant risk o malig-
nancy. However, data now suggest that the incidence
o gastric cancer is decreasing, thereby rendering
mandatory biopsy o all gastric ulcers unnecessary.
When gastric ulcers have eatures suggestive o
malignancy such as elevated irregular olds, associa-
tion with a polypoid or ungated mass, and abnor-
mal adjacent mucosal olds, then biopsy is warranted
(Fig. 23-1). Several biopsies, typically 6 or more,
are necessary to minimize the alse negative risk. I
benign ulcers are diagnosed, then EGD is repeated in
6 weeks to ensure resolution. All ulcers should be ol-
lowed and biopsied until complete resolution occurs.
I malignancy is detected, then urther work-up with
potential operative intervention is pursued.
Ulcers with a diameter o 3 cm or greater are termed
giant gastric ulcers (Fig. 23-2). T ese large ulcers
harbor an underlying malignancy in 30% o lesions.
Given the higher incidence o malignancy, per oration,
and bleeding surgical treatment is warranted.
2. B. EUS is important in preoperative locoregional
staging or gastric cancer. It is currently the best
imaging modality or assessing both tumor depth and
nodal invasion. Spatial resolution o 0.1 mm can be
achieved with EUS. staging accuracy ranges rom
60% to 90%, whereas N staging accuracy ranges rom
50% to 80%. EUS is better at identi ying 1 (80%) and
3 (90%) lesions as opposed to 2 (38.5%). EUS is not
reliable at delineating between individual benign and
Figure 23-1 Endoscopic view o an ulcerated ungating gastric
mass (white arrow) with irregular mucosal olds (black arrow).
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C H AP TER 2 3 G As TRi C C An C ER 83
Figure 23-2 Ex vivo surgical specimen containing giant gas-
tric ulcer (white arrow). Note the ulcerated, necrotic center
with irregular circum erential mucosal olds. Final pathology
revealed a poorly dif erentiated adenocarcinoma.
malignant lymph nodes. Increasing stage directly
correlates with increased risk o nodal and distant
metastasis (> 80% likelihood o nodal metastasis in
3 disease versus < 5% in stage 1 m).
C remains an important preoperative tool to
evaluate or metastatic disease. I metastatic disease
is present, an unnecessary operation can be avoided.
staging accuracy with C approaches 80% (66%
to 77%). N stage determination is variable with a
wide range o 25% to 86%. Small gastric tumors and
metastases less than 5 mm can be missed on C .
C , MRI, and PE scanning show promise or pre-
operative staging, but have yet to become standard
o care.
Routine diagnostic laparoscopy to minimize
unnecessary operations has become a less popular
pre-resection strategy. However, diagnostic lapa-
roscopy still has a role in advanced gastric cancer.
Power et al., in 2009, evaluated patients with known
gastric cancer without obvious metastitc disease and
strati ed them into low-risk ( 12, N0) and high-
risk ( 34, N+ , or both) groups based on EUS. Both
groups underwent diagnostic laparoscopy, which
identi ed M1 disease in 20.5% o the high-risk
patients and 4% o the low-risk patients. T e study
concluded that laparoscopy can be avoided in patients
with EUS early stage cancer, whereas more advanced
gastric cancers would bene t rom diagnostic lapa-
roscopy to rule out occult metastatic disease. When
diagnostic laparoscopy is per ormed, peritoneal
lavage cytology should be obtained as positive results
84 G En ERAL s U RG ERY EXAM i n ATi O n An D BO ARD REVi EW

can alter urther therapy. Diagnostic laparoscopy, thereby increasing the risk o microscopic residual
however, does not address the or N stage. positive margin (R1 resection). In order to minimize
the risk o leaving microscopic disease or recurrence,
3. A. Although the patient will ultimately need an a 5 to 6 cm margin is considered acceptable or an R0
operation, the MAGIC trail demonstrates that the resection. Newer studies emerging rom Japan sug-
patient will bene t rom neoadjuvant therapy instead gest that smaller proximal resection margins o 2 to
o proceeding straight to the operating room, unless 3 cm are adequate or 1 lesions. I the patient went
the patient is hemorrhaging rom the mass resulting straight to surgery, total gastrectomy is pre erred as
in hemodynamic instability. Neoadjuvant therapy the tumor is within 5 cm o the gastroesophageal
consisting o epirubicin, cisplatin, and uorouracil is junction. Esophagogastrectomy is unnecessary when
recommended or patients with 2 lesions or higher. the gastroesophageal junction has no direct tumor
T e bene ts rom the preoperative therapy are to involvement and surgical margins exceed 5 cm.
reduce tumor size and stage, eliminate micrometas- Assessing nodal disease at the time o operation
tases, improve tumor-related symptoms, and deter- can be di cult. A minimum o 15 lymph nodes is
mine whether tumors are sensitive to chemotherapy. recommended or staging. Most surgeons tend to
Gastric adenocarcinoma exists as two distinct enti- remove the perigastric lymph nodes (D1 resection).
ties: dif use and intestinal type. able 23-1 summarizes In countries like Japan where gastric cancer has a
these distinct subtypes. Controversies surrounding the higher prevalence, a more aggressive D2 lymphad-
surgical management o gastric adenocarcinoma enectomy is requently employed harvesting lymph
include: adequacy o surgical margins, need or resec- nodes along the celiac trunk and its named branches,
tion o adjacent structures (i.e. spleen and distal pan- the middle colic artery, the superior mesenteric
creas), and extent o lymphadenectomy. Dif use type artery, and the periaortic area. Several studies have
gastric adenocarcinoma spreads in the submucosa, demonstrated prolonged survival with the more
aggressive (D2) lymphadenectomy. T is is thought
able 23-1 SUMMARY COMPARING IN ES INAL to be related to better locoregional disease control.
AND DIFFUSE GAS RIC ADENOCARCINOMA A recent randomized trial comparing D1 versus D2
lymphadenectomy did not reveal a signi cant di -
Characteristic Intestinal Di use erence in long-term survival. Accordingly, more
Age Older Younger studies regarding the extent o lymphadenectomy
are required be ore a long-term endorsement o this
Gender Male > Female Male = Female
more aggressive strategy can be made.
Metastatic Hematologic Lymphatic, sub- Removal o adjacent structures (i.e., distal pan-
route mucosal spread creas and spleen) con er no survival bene t and
which can result
in a thickened,
actually increase morbidity and mortality. Resection
non-distensible o these adjacent structures should be reserved or
stomach known as primary tumor invasion.
linitis plasticans
Site o Liver Peritoneum 4. E. T e nal pathology revealed Stage III gastric can-
metastasis cer. Given the high rate o locoregional ailure (40% to
Risk actors Atrophic gas- CHD-1 mutation, 70%) and a 5-year survival rate o 20% to 28%, adju-
tritis, intestinal obesity vant therapy is recommended. T is recommendation
metaplasia, originates rom the Intergroup rial 0116, which dem-
Helicobacter onstrated a bene t or those patients with advanced
pylori in ection, gastric cancer undergoing curative resection combined
and diet high in
salt, smoked, and with postoperative uorouracil-based chemotherapy
preserved oods and radiation. T e CLASSIC trial demonstrated sur-
vival advantages using an adjuvant chemotherapy
Cellular Glandular Lamina propria
etiology gastric mucosa therapy regimen o capecitabine and oxaliplatin.
Resection without adjuvant therapy resulted in
Prognosis Better Poor
decreased survival when compared with those who

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received postoperative chemoradiation. Palliation
can be achieved with either external-beam radia-
tion or chemotherapy, but local control and long-
term survival are poor. Imatinib is a tyrosine-kinase
inhibitor currently used or gastrointestinal stromal
tumors and other malignancies.
5. D. In general, physical ndings portend advanced
disease. Patients are typically cachectic and jaundiced
when nodal metastatic disease obstructs the com-
mon bile duct. Irishs node is an enlarged lymph node
within the le axilla. A prerectal mass palpable on
digital rectal examination is a Blumers shel sugges-
tive o a drop metastasis. Virchows node, also known
as roisiers sign, re ers to carcinomatous involvement
o the le supraclavicular lymph nodes at the junc-
tion o the thoracic duct with the subclavian vein.
Krukenberg tumors are ovarian masses rom meta-
static gastric cancer. T e Sister Mary Joseph node is a
periumbilical nodule suggestive o carcinomatosis. It
re ects tumor extension rom the alci orm ligament.
BIBLIOGRAPHY
Al-Re aie WB, Abdalla EK, Ahmad SA, Mans eld PF. Gastric
Cancer. In: Fieg BW, Berger DH, Fuhrman GM, eds. T e
M D Anderson Surgical Oncology Handbook. 4th ed. Phila-
delphia, PA: Lippincot Williams & Wilkins; 2006:20540.
Arrington AK, Nelson R, Patel SS, et al. iming o chemother-
apy and survival in patients with resectable gastric adeno-
carcinoma. WJGNE . 2013;5:3218.
Bang YJ, Kim YW, Yang HK, et al. Adjuvant capecitabine
and oxaliplatin or gastric cancer a er D2 gastrectomy
(CLASSIC): a phase 3 open-label, randomised controlled
trial. Lancet. 2012;379:31521.
http://surgerybook.net/
C H AP TER 2 3 G As TRi C C An C ER 85
Committee ASoP, Banerjee S, Cash BD, et al. T e role o
endoscopy in the management o patients with peptic
ulcer disease. Gastrointestinal endoscopy. 2010;71:6638.
De Angelis C, Pellicano R, Man re SF, Rizzetto M. Endoscopic
ultrasound in the 2013 preoperative evaluation o gastric can-
cer. Minerva gastroenterologica e dietologica. 2013;59: 112.
Degiuli M, Sasako M, Ponti A, et al. Randomized clinical trial
comparing survival a er D1 or D2 gastrectomy or gastric
cancer. BJS. 2014;101:2331.
Joensuu H, Eriksson M, Sundby, Hall K, et al. One versus three
years o adjuvant imatinib or operable gastrointestinal stro-
mal tumor: a randomized trial. JAMA. 2012;307:126572.
Macdonald JS, Smalley SR, Benedetti J, et al. Chemoradiother-
apy a er surgery compared with surgery alone or adeno-
carcinoma o the stomach or gastroesophageal junction.
NEJM. 2001;345:72530.
McLoughlin JM. Adenocarcinoma o the stomach: a review.
Proceedings. 2004;17:3919.
Naeem AN, Mu eed S, Makary MA. T e Stomach. In: Cam-
eron JL, Cameron AM, eds. Current Surgical T erapy. 10th
ed. Philadelphia, PA: Elsevier; 2011:6392.
Pavlidis E, Pavlidis E , Sakantamis AK. T e role o laparo-
scopic surgery in gastric cancer. JMAS. 2012;8:358.
Power DG, Schattner MA, Gerdes H, et al. Endoscopic ultra-
sound can improve the selection or laparoscopy in patients
with localized gastric cancer. Journal o the American College
o Surgeons. 2009;208:1738.
Shin D, Park SS. Clinical importance and surgical decision-
making regarding proximal resection margin or gastric
cancer. WJGO. 2013;5:411.
Stolte M, Seitter V, Muller H. Improvement in the quality o
the endoscopic/bioptic diagnosis o gastric ulcers between
1990 and 1997An analysis o 1,658 patients. Zeitschrif
ur Gastroenterologie. 2001;39:34955.
Wu CW, Hsiung CA, Lo SS, et al. Nodal dissection or patients
with gastric cancer: a randomised controlled trial. T e Lancet
Oncology. 2006;7:30915.
 24
Gastrointestinal Stromal umors
William Cole
A 62-year-old man with hypertension was re erred
to the general surgery clinic or urther evaluation o
chronic abdominal pain, bloating, and early satiety,
which had been worsening over several months. He was
previously healthy except or hypertension controlled
with metoprolol and a history o inguinal hernia repair.
His last screening colonoscopy per ormed 2 years ago
was negative. On review o systems, he endorses sig-
ni cant atigue. Laboratory results are consistent with
mild anemia. An abdominal C scan was obtained or
urther evaluation and revealed a large tumor o gastric
origin (pictured below).
Reproduced with permission rom Lua S et al. Imaging o
gastrointestinal stromal tumor (GIS ). Clin Radiol. 2004;
59:48798.
1. T e best next step to de nitively diagnose this
lesion is:
A. Abdominal MRI
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B. Endoscopic ultrasound with FNA
C. Percutaneous image-guided biopsy
D. Diagnostic laparoscopy with biopsy and perito-
neal washings
2. Biopsied tissue is positive or KI (CD117) upon
immunochemical staining. Which o the ollowing
is true o this type o tumor?
A. Gastrointestinal stromal tumor (GIS ) most
commonly arises rom the stomach.
B. T e most common subtype is epithelioid.
C. A positive stain or KI (CD117) is required to
make the diagnosis o GIS .
D. T e most common site o metastatic spread is
the peritoneum.
E. All tumors >1 cm should be considered poten-
tially malignant.
3. Further review o the C scan raises concerns
that this 6-cm tumor may involve the neck o the
pancreas. T ere is no evidence o distant metastatic
disease. Further therapy in this case should include:
A. Surgical resection with en-bloc removal o the
involved pancreas to achieve 1 cm negative
margins.
B. Neoadjuvant imatinib prior to surgical therapy.
C. Avoidance o pancreatectomy by enucleation o
the tumor.
D. An open rather than laparoscopic approach
should be used.
E. An extended lymphadenectomy should be per-
ormed.
 C H AP TER 2 4 G As TRo i n TEs Ti n Al s TRo m Al Tu m o Rs
4. Af er appropriate therapy, nal pathology returns
with a GIS o gastric origin, 6 cm in greatest
dimension with 15 mitoses per high-power eld.
Which o the ollowing is true regarding this patient?
A. Adjuvant therapy with imatinib will increase his
chance o recurrence- ree and overall survival at
5 years.
B. I this lesion were in the small bowel, the progno-
sis would be better.
C. T is patient is at low risk o tumor recurrence.
D. Five year overall survival or all GIS patients is
about 50%.
5. Which o the ollowing is true o gastrointestinal
stromal tumors?
A. Because they arise rom the mucosa, GIS s are
easily identi ed at endoscopy.
B. Surgical resection is o en appropriate or
patients with recurrent or metastatic GIS .
C. T ese tumors arise rom the smooth-muscle
cells o the intestinal wall.
D. GIS tends to arise as a solitary lesion.
E. Abdominal pain is the most common clinical
mani estation o GIS .
ANSWERS
1. B. T e C slice shown demonstrates a large, well-
demarcated, heterogeneously enhancing mass that
appears to grow outward rom the wall o the stomach.
T ese ndings are characteristic o gastric GIS ,
although the di erential diagnosis includes gastric
adenocarcinoma, carcinoid, lymphoma, or leiomyosar-
coma, as well as tumors o pancreatic, renal, or adrenal
origin. GIS is a relatively uncommon neoplasm, with
an incidence o about 7 per million population in the
United States and Europe. T e bene ts o EUS include
de ning the layer o stomach wall rom which the
tumor originates, delineating its relationship to sur-
rounding structures, and obtaining a tissue diagnosis
transluminally, which avoids the risk o seeding a per-
cutaneous biopsy tract. Percutaneous image-guided
biopsy may result in intraperitoneal tumor spillage or
hemorrhage as a result o the riable, vascular nature o
these tumors and is there ore less desirable. MRI o ers
no additional bene t over C diagnostically, though it
may provide more in ormation regarding the tumors
relationship to surrounding tissues. Diagnostic lapa-
roscopy with peritoneal washings or cytology has a
prognostic role in gastric adenocarcinoma, but a simi-
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87
lar role has not been established in GIS . Laparoscopic
excision o the lesion may be per ormed without a
tissue diagnosis or a small tumor, but the goal in this
case is resection to clear margins, rather than simply
to obtain tissue or diagnostic purposes and there ore,
endoscopic ultrasound is the best choice.
2. A. T e presence o the c-kit receptor tyrosine kinase
on tumor cells, as in this case, is diagnostic o GIS .
However, it is noteworthy that about 5% o gastroin-
testinal stromal cells tumors are KI -negative and only
about 80% have a KI mutation. Other use ul histo-
logic markers include CD34 and smooth-muscle actin,
i KI negative GIS is suspected. T e most common
histologic subtype is the spindle-cell variety (70%), ol-
lowed by epithelioid (20%) and mixed subtypes (10%).
All tumors greater than 2 cm in size should be consid-
ered malignant, even in the absence o metastases on
initial work-up. T e most common site o metastatic
spread o GIS is the liver, ollowed by the omentum
and peritoneum. I present, these metastases are o en
identi ed by contrast enhanced C scanning. Metasta-
sis to the lymph nodes, lung, or other distant sites may
occur, but this is quite rare. T us, extended surgical
lymphadenectomy is not indicated or these tumors.
Over hal o all GIS s arise rom the stomach, making
it the most common primary site.
3. B. When surgical morbidity can be reduced by its use,
preoperative therapy with imatinib, a receptor tyrosine
kinase inhibitor, should be strongly considered. In this
case, tumor down-staging could potentially eliminate
involvement with the pancreas and obviate the need
or pancreatectomy. For localized GIS , surgical resec-
tion is indicated and is curative or low risk lesions. I
necessary to achieve an R0 resection, en-bloc removal
o involved organs outside the primary site is indi-
cated. However, there is no additional survival bene t
to resection beyond microscopically negative margins.
An extended lymphadenectomy also o ers no bene t
to the patient, as nodal metastasizes are uncommon
with GIS occurring about 1% o the time.
Enucleation o the tumor risks violating its pseu-
docapsule which may result in intraoperative tumor
spillage, resulting in recurrence rates approaching
100%. T ough laparoscopic surgery or GIS has
not been prospectively evaluated, there is good ret-
rospective evidence to show adequate oncologic
outcomes with this approach. Rates o R0 resection
between 97% and 100% and disease ree survival
88 G En ERAl s u RG ERY EXAm i n ATi o n An D Bo ARD REVi EW
and overall survival rates o over 90%. In the past, an
open approach or tumors larger than 5 cm has been
recommended. Current guidelines indicate that lapa-
roscopy is appropriate or larger tumors, providing
sound oncologic principles are maintained.
4. A. umor size, mitotic rate, and location are impor-
tant prognostic actors in GIS . umors with a size
< 5 cm have a 5-year overall survival o about 70%.
T is drops to about 45% when tumor size is > 10 cm.
Similarly, about 75% o patients with < 5 per
high-power eld will survive 5 years, only 20% o
those with more than 5 per high-powered eld are
alive at 5 years. umors o gastric origin are more
avorable than those originating in the small bowel,
with survival rates o approximately 75% and 50%,
respectively, a er 5 years. umor rupture be ore or
during surgery also portends a poor prognosis, as dis-
cussed above. Given the mitotic rate o the tumor in
this case, the patient has a relatively poor prognosis.
Adjuvant therapy with imatinib or 1 year has been
shown to increase recurrence ree survival by 15%
and, i continued or 3 years, improve 5-year overall
survival by 10%. However, about hal o all patients
will develop resistance to the drug within 2 years
o its initiation. For these patients, other tyrosine
kinase inhibitors (i.e. sunitinib) remain e ective sec-
ond line therapy. Historically, the overall survival or
all patients with GIS at 5 years has been about 50%.
However, in the era o imatinib, the 5-year OS has
improved to 84%, though survival varies markedly
between patients with Stage 1 tumors (nearly 100%)
versus more Stage 3 and higher tumors (22%).
5. D. Gastrointestinal stromal tumors are more likely to
be solitary than multiple. T is stands in contrast to
carcinoid tumors, which o en occur multiply. T ey
arise rom the muscular layer o the intestinal wall, but
rom the interstitial cells o Cajal, not the smooth mus-
cle cells. T eir location in the muscular layer can make
small GIS s somewhat dif cult to detect and lead to
underestimation o tumor extent by endoscopy.
At presentation, GIS is requently ound to be
metastatic, most commonly to the liver or perito-
neum. Presenting symptoms may include abdominal
pain, dyspepsia, or early satiety, but gastrointestinal
bleeding is the most common occurrence, leading
to the eventual diagnosis o a GIS . Li e-threatening
hemorrhage rom intraperitoneal rupture o these
highly vascular tumors may also occur. Generally
speaking, imatinib chemotherapy is considered rst
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line therapy or metastatic or recurrent GIS and
surgical resection is o en inappropriate due to high
rates o recurrence. However, some patients with
tumors response to imatinib and lesions that are elt
to be completely resectable may bene t.
BIBLIOGRAPHY
D,ematteo RP et al. umor mitotic rate, size, and location
independently predict recurrence a er resection o pri-
mary gastrointestinal stromal tumor (GIS ). Cancer. 2008;
112:60815.
Dematteo RP, et al. Results o tyrosine kinase inhibitor therapy
ollowed by surgical resection or metastatic gastrointesti-
nal stromal tumor. Ann Surg. 2007;245:34752.
Dematteo RP, et al. Long-term results o adjuvant imatinib
mesylate in localized, high-risk, primary gastrointestinal
stromal tumor. Ann Surg. 2013;258:4229.
Demetri GD, et al. NCCN task orce report: update on the
management o patients with gastrointestinal stromal
tumors. J Natl Compr Canc Netw. 2010;8:S1S41.
Emory S, Sobin LH, Lukes L, Lee DH, OLeary J. Prognosis
o gastrointestinal smooth-muscle stromal tumors: depen-
dence on anatomic site. Am J Surg Pathol. 1999;23(1):827.
Eisenberg BL, et al. Phase II trial o imatinib mesylate (IM)
or advanced primary and metastatic/recurrent operable
gastrointestinal stromal tumor (GIS )early results o
R OG 0132. J Surg Oncol. 2009;99(1):427.
Gervaz P, Huber O, Morel P. Surgical management o gastro-
intestinal stromal tumors. Brit J Surg. 2009;96:56778.
Gold JS, DeMatteo RP. Combined surgical and molecular ther-
apy: the gastrointestinal stromal tumor model. Ann Surg.
2006;244:17684.
Hohenberger P, et al. Pattern o recurrence in patients with rup-
tured primary gastrointestinal stromal tumor. Brit J Surg.
2010;97;18549.
Joensuu H, et al. One versus three years o adjuvant imatinib
or operable gastrointestinal stromal tumor. JAMA. 2012;
307(12):126572.
Joensuu H, Hohenberger P, Corless C. Gastrointestinal stromal
tumour. Lancet. 2013;382:97383.
Lee SD, et al. Prognostic signi cance o peritoneal washing
cytology in patients with gastric cancer. Br J Surg. 2012;
99(3):397403.
Lua S, et al. Imaging o gastrointestinal stromal tumor (GIS ).
Clin Radiol. 2004;59:48798.
Novitsky YW, Kercher KW, Sing RF, Heni ord B . Long-term
outcomes o laparoscopic resection o gastric gastrointesti-
nal stromal tumors. Ann Surg. 2006;243:73847.
Rutkowski P, et al. Clinical utility o the new American Joint
Committee on Cancer staging system or gastrointestinal
stromal tumors. Cancer. 2011;117:491624.
Sepe PS, Brugge WR. A guide or the diagnosis and manage-
ment o gastrointestinal stromal cell tumors. Nat Rev Gastro-
enterol Hepatol. 2009;6(6):36371.
abrizian P, Sweeney RE, Uhr JH, Nguyen SQ, Divino CM.
Laparoscopic resection o gastric and small bowel gastro-
intestinal stromal tumors: 10-year experience at a single
center. J Am Coll Surg. 2014;218:36773.
 25
Gastric Lymphoid umors

Cletus A. Arciero

A 56-year-old man with a 4-month history o vague epi- D. Partial/total gastrectomy with no lymph node
gastric abdominal pain, decreased appetite and weight dissection
loss presents to his local gastroenterologist or evalua- E. Surgical resection is not warranted in most cases
tion. An esophagogastroduodenoscopy (EGD) reveals
non-speci c gastritis and a polypoid lesion in the region 3. First line therapy or a MAL lymphoma as noted
o the antrum. Laboratory ndings note mild anemia, in the patient above would consist o which o the
elevated LDH, and H. pylori positive samples rom the ollowing?
EGD. A. Surgical resection
Follow-up endoscopic ultrasound (EUS) notes a B. Radiation therapy
thickened antral wall, and multiple biopsies obtained C. Chemotherapy
reveal an extra-nodal marginal zone B cell lymphoma D. H. pylori eradication
o mucosa (gut)-associated lymphoid tissue (MAL ) E. Watch ul waiting
type (MAL lymphoma). Computed tomography o the
chest, abdomen, and pelvis reveals thickening o the dis- 4. What is the management or persistent, localized,
tal hal o the stomach with no evidence o adenopathy. MAL lymphoma ollowing repeatedly ailed
Bone marrow biopsy reveals no evidence o disease dis- ef orts at H. pylori eradication therapy?
semination. A. Radiation therapy
B. Surgical resection
1. A er the patient has undergone a complete staging C. Chemotherapy
work-up as noted above, what stage low-grade D. Rituximab
gastric MAL lymphoma does this patient have? E. Bevacicumab
A. Stage I
B. Stage II 5. How does the treatment strategy change in patients
C. Stage III with high-grade gastric lymphoma (advanced MAL
D. Stage IV lymphoma or dif use large B-cell lymphoma)?
E. Unknown A. Surgical resection
B. Radiation therapy alone
2. T e proper surgical management o this patient C. Chemotherapy alone
with gastric lymphoma is: D. H. pylori eradication
A. otal gastrectomy with D2 lymph node dissection E. Combined chemotherapy with or without radia-
B. otal gastrectomy with D1 lymph node dissection tion therapy
C. Partial gastrectomy with D1 lymph node dissection

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90 G EN ERAL S U RG ERY EXAM I N ATIO N AN D BO ARD REVI EW
ANSWERS
1. A. T e staging o gastric lymphoma is paramount
in the proper management o the disease. Although
o en indolent, approximately 10% o patients with
gastric lymphoma will present with advanced disease.
EGD allows or visualization o the lesion and o en
tissue sampling as well as H. pylori diagnosis. Endo-
scopic ultrasound is also an important diagnostic
procedure that can determine extent o disease, depth
o invasion, and o en allows more complete tissue
sampling. EUS also allows or accurate estimates o
depth o invasion, which is an important prognostic
marker or disease recurrence. C o the chest, abdo-
men, and pelvis is important to assess or dissemi-
nated disease while a bone marrow biopsy will detect
evidence o distant disease in up to 15% o patients.
Standard laboratory testing includes complete blood
count and LDH, as well as other standard chemistries.
Based on the National Comprehensive Cancer
Network (NCCN) Clinical Practice Guidelines, the
Lugano Staging System or Gastrointestinal Lym-
phoma is adequate. T is modi cation o the Ann
Arbor Staging System is noted below, directly com-
pared with the Ann Arbor Staging System. Utiliz-
ing either staging system is appropriate. Based these
staging systems, the above patient has Stage I disease.
Lugano Staging System
Stage I - T e tumor is con ned to the gastroin-
testinal tract. It can be a single primary lesion or
multiple, noncontiguous lesions.
Stage II - T e tumor extends into the abdomen. T is
is urther subdivided based upon the location o
nodal involvement:
Stage II1: Involvement o local nodes (paragastric
nodes or gastric lymphoma or para-intestinal
nodes or intestinal lymphoma)
Stage II2: Involvement o distant nodes (para-
aortic, para-caval, pelvic, or inguinal nodes or
most tumors; mesenteric nodes in the case o
intestinal lymphoma)
Stage IIE: T e tumor penetrates the serosa to
involve adjacent organs or tissues
Stage III - T ere is no stage III disease in this
system.
Stage IV - T ere is disseminated extranodal
involvement or concomitant supra-diaphragmatic
nodal involvement.
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2. E. Gastric lymphoma is the second most common
gastric malignancy (behind gastric adenocarcinoma)
and the most requent cite o extra-nodal non-
Hodgkins Lymphoma. For decades, surgical resec-
tion was considered appropriate therapy or all stages
o resectable gastric lymphomas. Although surgical
resection has provided outstanding results and excel-
lent long-term survival, stomach preserving methods
have provided equivalent results without the mor-
bidity associated with gastrectomy (partial or total)
or both low-grade and high-grade B-cell lympho-
mas. A prospective trial by the German Multicenter
rial group in 2005 examined 185 patients with Stage
I and II low-grade gastric lymphoma and noted no
di erence in survival between those patients treated
surgically and those receiving no surgical interven-
tion. A ollow-up study by the same group exam-
ined an additional 393 patients and provided similar
results. T e results are similar or high-grade gastric
lymphomas, where survival rates between primary
surgery and primary chemotherapy and radiation
therapy groups is equivalent. Surgical intervention
or gastric lymphoma is largely reserved or rare
cases o per oration, or hemorrhage that cannot be
controlled endoscopically. Stomach preserving treat-
ment strategies are now the standard o care in the
management o gastric lymphoma.
Ann Arbor Staging System
Stage I - Involvement o a single lymph node region (I) or o a
single extralymphatic organ or site (IE)*
Stage II - Involvement o two or more lymph node regions or
lymphatic structures on the same side o the diaphragm alone
(II) or with involvement o limited, contiguous extralymphatic
organ or tissue (IIE)
Stage III - Involvement o lymph node regions on both sides o the
diaphragm (III), which may include the spleen (IIIS) or limited,
contiguous extralymphatic organ or site (IIIE) or both (IIIES)
Stage IV - Di use or disseminated oci o involvement o one
or more extralymphatic organs or tissues, with or without asso-
ciated lymphatic involvement

3. D. Gastric MAL lymphomas arise rom B-cells
and constitute approximately 50% o gastric lym-
phomas, with the di use large B-cell lymphoma
making up the other large proportion o gastric
lymphomas. Although surgical therapy was consid-
ered the mainstay o therapy or decades, in the late
1980s, a connection between Campylobacter (later
Helicobacter) pylori, chronic gastritis and mucosal
associated lymphoid tissue (MAL ) was suspected.
By the early 1990s, the connection between the two
was rmly established and the treatment o gastric
MAL lymphoma with H. pylori eradication was
instituted. A meta-analysis o 34 studies with 1271
patients noted an overall H. pylori eradication rate
o 98.3%, associated with a complete remission o
gastric lymphoma in 77.8% o patients. T e relapse
rate or patients was 2.2% per year, and only 0.05%
o patients had trans ormation o low-grade lym-
phoma into an aggressive, high-grade lymphoma.
Frequent endoscopic monitoring (3 month inter-
vals initially) is paramount to assess or treatment
response. Patients with pathology revealing clear-
ance o H. pylori and resolution o lymphoma will
require continued surveillance. T ose patients with
persistent H. pylori should receive additional eradi-
cation therapy. I gastric lymphoma persists despite
multiple rounds o anti-H. pylori therapy, the
addition o external beam radiation and/or chemo-
therapy is warranted.
Patients with H. pylori negative gastric MAL
lymphoma o en have a documented translocation
t(11;18), and thus eradication therapy is o en not
e ective. T ese patients are treated with radiation
therapy as rst-line therapy. Rituximab has shown
some e ectiveness in these patients as well, and is
currently considered in those patients with per-
sistent localized disease and a contraindication to
radiotherapy.
4. A. T e management o persistent, localized, early
stage gastric MAL lymphoma is radiation therapy.
Although there are various approaches taken in the
management o these patients, radiation therapy
(external beam, 3040 cGy) has shown excellent
results and is the recommended treatment by NCCN
guidelines. In general, rst-line salvage therapy pro-
vides remission rates o 90.1%. Radiation therapy was
superior to chemotherapy or surgery, with a 97.3%
remission rate versus 92.5% or surgery, and 85.3%
or chemotherapy. In act, radiation therapy as a sole
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C H AP TER 2 5 G AS TRIC LYM P H O I D TU M O RS 91
therapy was ound to be superior to even combined
modality approaches.
Further support or radiation therapy is provided
by Goda, et al. who noted an overall remission rate
o 92% with excellent long-term (10-year) survival
data. Additional studies show long-term remis-
sion rates o 88% to 97% (5 to 7.8 years). For some
patients with Stage I disease, chemotherapy may be
added to radiotherapy, but this is not considered the
standard approach. Chemotherapy or low-grade
gastric MAL lymphoma is typically reserved or
persistent Stage II disease or patient presenting with
more advanced disease (Stage IIE or IV). T e exact
chemotherapeutic regimen or advanced stage gas-
tric MAL lymphoma is not well established, but is
o en treated with agents utilized against ollicular
lymphomas.
5. E. As addressed earlier, surgical therapy has been
largely abandoned as the primary treatment o gas-
tric lymphoma, including patients with advanced
gastric MAL lymphoma and gastric di use large
B-cell lymphoma (DLBCL). A study examining the
long-term outcomes in patients treated with surgery
alone, surgery ollowed by radiation therapy, surgery
ollowed by chemotherapy and chemotherapy alone
noted that complete response rates were similar in
the 4 arms. But, survival was signi cantly improved
in patients receiving chemotherapy, with no clear
bene t to combined modality therapy with surgery
and chemotherapy. In act, late toxicity was more re-
quent and severe in patients who had surgery.
In terms o H. pylori eradication, studies are ongo-
ing. It was once thought that there was little bene t in
treating H. pylori in these patients, since there was no
MAL component in most patients. Although there
are cases exhibiting both gastric MAL lymphoma
and DLBCL, rst-line therapy was typically targeted
at the more aggressive entity. Recently, there has
been some success noted with H. pylori eradication
in early stage DLBCL patients that are H. pylori posi-
tive. In comparing patients with pure gastric DLBCL
and mixed (MAL and DLBCL), H. pylori eradica-
tion rates were 100% and 94.1%, respectively. Remis-
sion rates were 68.8% or pure DLBCL and 56.3% or
the mixed gastric DLBCL. Prospective studies are
ongoing. Currently, chemotherapy, with or without
biologic therapy, is considered rst-line therapy or
gastric DLBCL, which is considered the more aggres-
sive o the two most common gastric lymphomas.
92 G EN ERAL S U RG ERY EXAM I N ATI O N AN D BO ARD REVI EW
NCCN clinical practice guidelines note that Stage I
and II disease are treated with chemotherapy with
localized radiation therapy added in certain cases.
T e chemotherapeutic regimens utilized vary, but
the most common regimen combines cyclophos-
phamide, doxorubicin, vincristine, and prednisone
(CHOP) and o en the addition o a biologic agent
(riuximab) (R-CHOP). T e CHOP regimen shows
complete remission (CR) rates o 87% to 100% with
good long-term survival. An examination o the
R-CHOP regimen reveals similar statistics with a CR
rate o 87%, with the remaining 13% exhibiting a par-
tial remission. T e addition o radiation therapy or
early stage disease has been examined and there was a
notable decrease in local recurrences in those patients
treated with radiation therapy. But, radiation therapy
did not add to overall survival when compared with
chemotherapy alone. Overall, radiation therapy is
selectively added to chemotherapy in patients with
gastric DLBCL, speci cally or local control.
For patients with more advanced disease (speci -
cally Lugano Stage IV), chemotherapy alone is uti-
lized with radiation therapy reserved as needed or
local control o symptoms.
BIBLIOGRAPHY
Aleman BM, Haas RL, van der Maazen RW. Role o radiother-
apy in the treatment o lymphomas o the gastrointestinal
tract. Best Pract Res Clin Gastroenterol. 2010;24(1):2734.
Andriani A, Zullo A, Di Raimondo F, Patti C, edeschi U,
Caruso L, et al. Clinical and endoscopic presentation o
primary gastric lymphoma: a multicenter study. Aliment
Pharmacol T er. 2006;23:72126.
Avils A, Neri N, Nambo MJ, Huerta-Guzman J, Cleto S. Sur-
gery and chemotherapy versus chemotherapy as treat-
ment o high-grade MAL gastric lymphoma. Med Oncol.
2006;23(2):295300.
Avils A, Nambo MJ, Neri N, Huerta-Guzman J, Cuadra I,
Alvarado I, et al. T e role o surgery in primary gastric
lymphoma: results o a controlled clinical trial. Ann Surg.
2004;240(1):4450.
Cavalli F, Isaacson PG, Gascoyne RD, et al. MAL lympho-
mas. Hematology Am Soc Hematol Educ. Program 2001;
24158.
Eidt S, Stolte M, Fischer R. Helicobacter pylori gastritis and
primary gastric non-Hodgkins lymphomas. J Clin Pathol.
1994;47(5):4369.
Goda JS1, Gospodarowicz M, Pintilie M, et al. Long-term
outcome in localized extranodal mucosa-associated lym-
phoid tissue lymphomas treated with radiotherapy. Cancer.
2010;116(16):381524.
Janssen J. T e impact o EUS in primary gastric lymphoma.
Best Pract Res Clin Gastroenterol. 2009;23:6718.
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Koch P, del Valle F, Berdel WE, Willich NA, Reers B,
Hiddemann W, et al. Primary gastrointestinal non-
Hodgkins lymphoma: II. Combined surgical and conser-
vative or conservative management only in localized gastric
lymphomaresults o the prospective German Multicenter
Study GI NHL 01/92. J Clin Oncol. 2001;19(18):387483.
Koch P, Probst A, Berdel WE, et al. reatment results in local-
ized primary gastric lymphoma: data o patients registered
within the German multicenter study (GI NHL 02/96).
J Clin Oncol. 2005;23(28):70509.
Kuo SH, Yeh KH, Wu MS, Lin CW, Hsu PN, Wang HP, et al.
Helicobacter pylori eradication therapy is e ective in the
treatment o early-stage H pylori-positive gastric di use
large B-cell lymphomas. Blood. 2012;119(21):483844.
Liu H, Ye H, Ruskone-Fourmestraux A, De Jong D, Pileri S,
T iede C, et al. (11;18) is a marker or all stage gastric
MAL lymphomas that will not respond to H. pylori eradi-
cation. Gastroenterology. 2002;122(5):128694.
Martinelli G, Gigli F, Calabrese L, Ferrucci PF, Zucca E, Crosta
C, et al. Early stage gastric di use large B-cell lymphomas:
results o a randomized trial comparing chemotherapy
alone versus chemotherapy and involved eld radiother-
apy. (IELSG 4). Leuk Lymphoma. 2009;50(6):92531.
Martinelli G, Laszlo D, Ferreri AJ, Pruneri G, Ponzoni M,
Conconi A, et al. Clinical activity o rituximab in gastric
marginal zone non-Hodgkins lymphoma resistant to or
not eligible or anti-Helicobacter pylori therapy. J Clin
Oncol. 2005;23(9):197983.
National Comprehensive Cancer Network. National Compre-
hensive Cancer Network Clinical Guidelines: Non-Hodkins
Lymphoma, Version 2. 2014. Accessed from www.nccn.org.
Raderer M, Chott A, Drach J, Montalban C, Dragosics B, Jger
U, et al. Chemotherapy or management o localised high-
grade gastric B-cell lymphoma: how much is necessary?
Ann Oncol. 2002;13(7):10948.
Rohatiner A, dAmore F, Coif er B, Crowther D, Gospodaro-
wicz M, Isaacson P, et al. Report on a workshop convened
to discuss the pathological and staging classi cation o gas-
trointestinal tract lymphoma. Ann Oncol. 1994;5:397400.
Ruskon-Fourmestraux A, Fischbach W, Aleman BM, Boot H,
Du MQ, Megraud F, et al. EGILS consensus report. Gastric
extranodal marginal zone B-cell lymphoma o MAL . Gut.
2011;60(6):74758.
Seiichiro A, Ichiro O, Koji I, Haruhisa S, Shigetaka Y, Satoru N,
et al. A retrospective study o 5-year outcomes o radio-
therapy or gastric mucosa-associated lymphoid tissue
lymphoma re ractory to Helicobacter pylori eradication
therapy. Jpn J Clin Oncol. 2013;43(9):91722.
Stolte M, Eidt S. Lymphoid ollicles in antral mucosa:
immune response to Campylobacter pylori? J Clin Pathol.
1989;42(12):126971.
Wirth A, Gospodarowicz M, Aleman BM, et al. Long-term
outcome or gastric marginal zone lymphoma treated with
radiotherapy: a retrospective, multi-centre, International
Extranodal Lymphoma Study Group study. Ann Oncol.
2013;24(5):134451.
Whrer S, Pspk A, Drach J, et al. Rituximab, cyclophospha-
mide, doxorubicin, vincristine and prednisone (R-CHOP)

or treatment o early-stage gastric di use large B-cell lym-
phoma. Ann Oncol. 2004;15(7):108690.
Ye H, Liu H, Raderer M, Chott A, Ruskone-Fourmestraux A,
Wotherspoon A, et al. High incidence o t(11;18)(q21;q21)
in Helicobacter pylori-negative gastric MAL lymphoma.
Blood. 2003;101(7):254750.
Zullo A, Hassan C, Andriani A, Cristo ari F, De Francesco V,
Ieradi E, et al. Eradication therapy or Helicobacter pylori
in patients with gastric MAL lymphoma: a pooled data
analysis. Am J Gastroenterol. 2009;104(8):19327.
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C H AP TER 2 5 G AS TRI C LYM P H O I D TU M O RS 93
Zullo A, Hassan C, Andriani A, Cristo ari F, De Francesco
V, Ieradi E, et al. E ects o Helicobacter pylori eradica-
tion on early stage gastric mucosa-associated lymphoid
tissue lymphoma. Clin Gastroenterol Hepatol. 2010;8(2):
10510.
Zullo A, Hassan C, Andriani A, et al. reatment o low-grade
gastric MAL -lymphoma unresponsive to Helicobacter
pylori therapy: a pooled-data analysis. Med Oncol. 2010;27(2):
2915.
 26
Gastroesophageal Re ux Disease

Mary . ODonnell and E. Matthew Ritter

SCENARIO 1 2. He is started on the medication and experiences

A 58-year-old male presents to your clinic with upper
abdominal pain and heartburn a er meals. He occasion-
ally relieves symptoms with chewable antacids (calcium
carbonate). He denies other problems except or gaining
5 lbs over the last year with decreased exercise. He has no
surgical history, takes no medications, and has no signi -
icant amily history. He used to smoke, but quit 15 years
ago and drinks 2 glasses o red wine each night.
1. Other than improving his diet and decreasing
his alcohol intake, what medication would you
prescribe to best limit his esophageal acid exposure?
A. Proton pump inhibitor (PPI)
B. H2 receptor antagonist (H2RA)
C. Calcium carbonate
D. Sucral ate as needed
relie . He returns to your clinic 1 year later, but
now the medication is no longer relieving his
symptoms. He also reports occasional cough and
the sensation that he has to clear his throat. What
should be your next step?
A. Esophagogastroduodenoscopy (EGD)
B. Per orm barium swallow
C. Per orm 24 hr ambulatory pH monitoring
D. Per orm pulmonary unction tests
3. He ollows up in 3 weeks with a barium swallow, pH
monitoring, and an EGD rom an outside provider.
He provides a copy o the 24 hr ambulatory pH
monitoring report to you, which can be viewed
below. He has a sliding ( ype I) hiatal hernia, and
no evidence o intestinal metaplasia or ulcers.

Acid Re ux Composite Score Analysis (Johnson/DeMeester) (pH)

T reshold Patient Value Patient Score Normal

Upright time in re ux 10.4% 5.1 < 6.3
Recumbent time in re ux 10.0% 21.9 < 1.2
otal time in re ux 10.2% 7.3 < 4.2
Episodes over 5 min 5.4 4.9 < 3.1
Longest episode 41.7 min 15.1 < 9.2
otal episodes 48.6 2.9 < 50.1
Composite score 57.1 < 22.0
NO E: Composite score patient values are normalized or 24 Hours.

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 C H AP TER 2 6 G As TRo Es o P H AG EAl REf l u x D i s EAs E 95

What is the intervention would you o er him at 6 months. She presents to the ER 12 hours later with
this time? rapid respirations, tachycardia, ever, and elevated
A. Esophagectomy WBC. Based upon your clinical suspicions, what is
B. Nissen undoplication the best initial diagnostic test?
C. Heller myotomy with Dor undoplication A. Gastrogra n esophagography
D. Botulinum toxin injection B. T in barium esophagography
C. C with IV contrast or PE/DV protocol
4. What is the most common long-term complication D. EGD
o a Nissen undoplication?
A. Stricture 3. A small intrathoracic per oration is conf rmed. In
B. Gastroesophageal leak your determination o a management plan, which
C. Gas bloat syndrome o the ollowing is an absolute contraindication to
D. Dysphagia non-operative management?
E. Slipped Nissen A. ime o per oration > 72 hrs
B. A history o Barretts esophagus with low grade
5. He undergoes a Nissen undoplication without dysplasia
complication and is discharged the ollowing C. Per oration contained in the mediastinum
day. Five days a er surgery, he returns or ollow D. Evidence o SIRS (systemic in ammatory
up appointment reporting le upper quadrant response syndrome)
pain. He is hemodynamically normal and has a
hemoglobin one point lower than his preoperative 4. T e patient has a small thoracic esophageal
values. C scan o the chest, abdomen, and pelvis per oration with a le sided e usion and is
shows a heterogeneous le upper quadrant uid developing low blood pressure. A er beginning
collection without rim enhancement and an resuscitation, you determine she needs to go to
associated small le pleural e usion. surgery or repair o the leak. Based upon the most
What is the most appropriate initial management likely location o these types o injuries, which
or this patient? incision would you use to expose the esophagus or
repair?
A. Admit or uids and observation
B. Admit or antibiotics and total parenteral nutrition A. Right posteriolateral thoracotomy
C. Return to the operating room B. Le posteriolateral thoracotomy
D. Percutaneous drainage C. Median sternotomy
D. Laparotomy
SCENARIO 2
A 63-year-old emale with a long history o gastro- ANSWERS O SCENARIO 1
esophageal re ux disease presents to your clinic a er a 1. A. T e mainstay o medical treatment o GERD is
gastroenterologist per orms an EGD. She is diagnosed acid suppression. Patients with persistent symptoms
with Barretts esophagus without evidence o dysplasia should be given PPIs, such as omeprazole. In doses
based upon the results o several biopsies. as high as 40 mg/d, they can ef ect an 80% to 90%
1. When should her next EGD with biopsy be reduction in gastric acidity. In patients with re ux
per ormed or appropriate surveillance? disease, esophageal acid exposure is reduced by up
to 80% with H 2RAs and up to 95% with PPIs. Despite
A. 3 months the superiority o the latter class o drug over the or-
B. 6 months mer, periods o acid breakthrough still occur.
C. 1 year
D. 3 years 2. A. I a er a year o success ul symptom relie ,
the symptoms are no longer controlled by a single
2. Her ollow-up EGD demonstrates Barretts medication and he has developed extraesophageal
esophagus with low-grade dysplasia on multiple symptoms (cough and sensation o postnasal drip)
biopsies, so she is scheduled or ollow up EGD in o GERD, then consideration should be given to

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96 G EN ERAl s u RG ERY Ex AM i N ATi o N AN D Bo ARD REVi EW
prescribing another PPI. It is important, though, to
rule out ulcers, malignancy, a hiatal hernia, esophagi-
tis or other esophageal, gastric, or duodenal erosive
pathology. T ere ore, EGD is the best option or
direct mucosal visualization.
I no other pathology can account or the symp-
toms, a 24-hour pH monitoring would be the next
step in diagnosis. T is would determine i acid re ux
is the cause o the patients symptoms. A barium
swallow could add some more in ormation but is
not diagnostic. Halitosis would be an indicator o
a diverticulum (Zenkers) or possibly achalasia in
which ood is retained within the esophagus. A better
study to evaluate these pathologies is barium swal-
low esophagram. Pulmonary unction tests are not
indicated or evaluation o the patients cough.
3. B. T e acid re ux composite score analysis shown
is consistent with the diagnosis o GERD. T ere ore,
a Nissen undoplication is an appropriate surgical
choice or this patient with re ractory GERD and a
sliding hiatal hernia. Since the patient does not have
high-grade dysplasia or evidence o esophageal can-
cer, esophagectomy would not be the correct choice.
T e patient has a type I sliding hiatal hernia, not a
paraesophageal hernia ( ypes II, III, and IV), there-
ore answer C would not be correct (see diagram).
Botulinum toxin and Heller myotomy with Dor
undoplication are used in the treatment o achalasia,
but would not be indicated in a patient with GERD.
4. D. Early complications o Nissen undoplication:
gastroesophageal leak, pneumothorax, abscess, and
hematoma. O these, the most common is dysphagia.
Late complications o Nissan undoplication: stric-
ture, gas bloat syndrome, wrap disruption, wrap her-
niation, and dysphagia.
5. A. Development o uid collection postoperatively
without instability in vital signs, ever, WBC or other
evidence o in ection is most suspicious or hema-
toma. T e development o the collection o ve days
postoperatively would indicate a slow bleed, not
1. GERD Dia gnos is a nd ma na ge me nt a ccording to S AGES GERD guide line s
2. Hia ta l he rnia
S ymptoma tic
As ymptoma tic
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requiring urgent reoperation. Percutaneous drainage
would increase the risk o introducing bacteria and
in ecting the uid collection. Conservative manage-
ment including hydration and observation is recom-
mended or a small, stable hematoma. Antibiotics are
not indicated without evidence o in ection.
ANSWERS O SCENARIO 2
1. C. Barretts esophagus without dysplasia has a risk
o 0.1% to 1% rate o progression to adenocarcinoma
and initial surveillance should be with annual EGD
with biopsy. Low grade dysplasia requires surveil-
lance every 6 months until no dysplasia is ound.
I no more dysplasia is ound, surveillance can be
extended to once every 3 years. High-grade dyspla-
sia has a 5-year risk o adenocarcinoma o 30% and
must be intervened upon with excision or ablation or
undergo endoscopic surveillance every 3 months.
2. A. T e patient has suf ered and iatrogenic esopha-
geal per oration. T e best initial test or diagnosis o
this is esophagram with water-soluble contrast such
as gastrogra n. I this does not demonstrate leak, thin
barium should be used next. T e WBC elevation and
acute nature o the presentation in relationship to the
EGD procedure makes PE less likely than esophageal
per oration. EGD would not be recommended in this
scenario as it could enlarge the per oration.
3. D. Operative management is imperative in the
patient who is becoming unstable (developing a SIRS
response) as it may become li e-threatening. It should
be considered i the per oration is not well-contained,
in the acute time period a er the procedure, or there
is associated malignancy. In contrast, non-operative
management should be considered i the time o per-
oration > 72 hrs, there is no evidence o associated
malignancy, or the per oration is well-contained.
4. B. T e surgical approach to the distal esophagus is
a le posteriolateral thoracotomy. Any esophageal
injury should be buttressed with other tissue like
GERD s ymptoms only
Non-GERD s ymptoms
Re fe r to the s e guide line s
 C H AP TER 2 6 G As TRo Es o P H AG EAl REf l u x D i s EAs E
nearby pleura, a pericardial at pad, pedicled inter-
costal muscle, or the diaphram.
BIBLIOGRAPHY
Castell, Donald O. Linda Diederich, June A. Castell. Esopha-
geal Motility and pH esting, echnique and Interpretation.
3rd ed. Highlands Ranch, CO: Sandhill Scienti c, Inc.;
2000.
Davis CS, Baldea A, Johns JR, Fisichella PM. T e evolution
and long-term results o laparoscopic antire ux sur-
gery or the treatment o gastroesophageal re ux dis-
ease. Journal of the Laparoendoscopic Surgeons. 2010;14:
33241.
Fernando H, Murthy SC, Ho stetter W, Shrager JB, Bridges B,
Mitchell J. T e Society o T oracic Surgeons Practice
Guideline Series: Guidelines or the management o
Barretts Esophagus with high grade dysplasia. Annals of
T oracic Surgery. 2009;87:19932002.
Hughes SGI, Chekan EG, Ali A, Reintgen KL, Eubanks WS.
Unusual complications ollowing laparoscopic Nissen
undoplication. Surg Laparosc Endosc Percutan ech. 1999;
9(2):1437.
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97
Peghini PL, Katz PO, Bracy NA, et al. Nocturnal recovery o
gastric acid secretion with twice-daily dosing o proton
pump inhibitors. Am J Gastroenterol. 1998;93:763.
Kohn GP, Price RR, Demeester SR, et al., SAGES Guidelines
Committee. Guidelines or the management o hiatal her-
nia. Surg Endosc. 2013;27:440928.
Laheij RJF, Sturkenboom MCJM, Hassing R-J. Risk o
community-acquired pneumonia and use o gastric acid-
suppressive drugs. JAMA. 2004;292:195560.
Morgenthal CB, Shane M, Stival A, et al. T e durability o lap-
aroscopic Nissen Fundoplication: 11-year outcomes. Jour-
nal of Gastrointestinal Surgery. 2007;11:693700.
Ozawa S, Kitajima M, Esophageal Per oration. In: Fischer JE,
Jones DB, Pomposelli FB, Upchurch GR Jr., Klimberg VS,
Schwaitzberg SD, et al. Fischers Masters of Surgery. 6th ed.
Philadelphia, PA: Lippincott Williams & Wilkins; 2011.
Ste anidis D, Hope WW, Kohn GP, Reardon PR, Richardson
WS, Fanelli RD, SAGES Guidelines Committee. Guidelines
or surgical treatment o gastroesophageal re ux disease.
Surg Endosc. 2010;24:264769.
Wang K, Sampliner RE. Updated guidelines 2008 or the
diagnosis, surveillance and therapy o Barrett sesophagus.
American Journal o Gastroenterology. Am J Gastroenterol.
2008;103:78897.
 27
Per orated Peptic Ulcer Disease

Henry Lin

A 78-year-old emale with arthritis and asthma presents E. Laparoscopic Graham patch with parietal cell
to the emergency room with an acute onset o epigastric vagotomy
pain a couple o hours ago. Her pulse is 104, her blood
pressure is unchanged rom her baseline o 110/74 mm 3. What testing should be done or ollow-up?
Hg, and her temperature is 98.2 Fahrenheit. Her medi- A. Secretin stimulation test
cations include occasional naproxen and prednisone or B. H. pylori stool antigen testing
occasional exacerbations o her asthma. On physical C. Emergent urea breath testing
exam, her abdomen demonstrates signi cant epigastric D. Colonoscopy
tenderness with rebound. She has a mild leukocytosis E. Both A and C
o 12.5 cells/mcL. Her acute abdominal series demon-
strates a small amount o ree air. 4. What urther ollow-up is necessary i she has no
urther symptoms?
1. What is the most reasonable current treatment A. Long-term intravenous pantoprazole
option or this patient as the next step? B. Nothing
A. Laparoscopic highly selective vagotomy without C. Chronic suppressive antibiotics
resuscitation D. Serum gastrin level
B. Nasogastric tube insertion, cessation o all oral E. Esophagogastroduodenoscopy with biopsy o
eeds, & intravenous uid initiation or the next ulcer i still present
24 hours
C. Open truncal vagotomy with pyloroplasty
ANSWERS
D. Open Graham patch with parietal cell vagotomy
despite laparoscopic experience and resources 1. B. O all the listed options, nasogastric tube inser-
E. Emergent anterior seromyotomy tion with NPO status and initiation o IV uid is
a very reasonable rst step in the modern era o
2. I she does not demonstrate improvement during H. pylori detection and treatment, especially in
the 12 hours af er onset o symptoms, what is the a stable patient. Graham patch with parietal cell
most reasonable and expedient next step? vagotomy is also a very reasonable option but an
A. runcal vagotomy with antrectomy and a Bilroth open approach is more problematic i laparoscopic
II reconstruction experience and resources are available. T e veri ca-
B. Continued observation tion o resuscitation is required prior to going to the
C. Selective angioembolization operating room or patients. T e veri cation in this
D. Laparoscopic Graham patch only and H. Pylori patient can simply be assessing volume status (e.g.,
testing with possible treatment urine output o 0.5 cc/kg/hour or normal heart rate

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 C H AP TER 2 7 P ERf o RATEd P EP Ti C U l C ER d i s EAs E
or a patient not on a beta-blocker. runcal vagot-
omy with pyloroplasty is not a rst-line treatment in
the modern era o H. Pylori. Anterior seromyotomy,
division o the seromuscular layer o the lesser cur-
vature in order to achieve a highly selective vagot-
omy e ect, is a reasonable approach but not as a rst
option.
2. D. Laparoscopic Graham patch with H. Pylori test-
ing and subsequent testing is the best choice o those
presented. runcal vagotomy with antrectomy is
no longer a rst- line option in the modern era o
H. Pylori detection and treatment. Observation is
not reasonable i the patient is not improving and a
more aggressive management choice is most likely
necessary. Angioembolization may be considered or
bleeding peptic ulcer disease in selective cases but
not or per oration o an ulcer. Parietal cell vagotomy
is no longer considered one o the early line treat-
ments but to be reserved as a treatment option or
re ractory peptic ulcer disease.
3. B. H. Pylori stool antigen testing is a very reasonable
approach and can even be ordered semi-emergently
in the emergency room at some institutions to help
in decisions with early treatment options. Secretin
stimulation test is utilized or gastrinoma work-up,
which is not yet necessary during this part o the
work-up or this patient since recalcitrant peptic
ulcer disease is not yet identi ed. Urea breath test-
ing or H. pylori is reasonable but is not an emergent
process as obtaining this test requires a clinical lab.
Colonoscopy is reasonable in a patient over the age
o 50 who has not had a screening process done but is
not required to address the ollow-up or peptic ulcer
disease per oration.
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99
4. E. Esophagogastroduodenoscopy (EGD) is neces-
sary to rule out a gastric carcinoma that caused the
per oration, especially in older patients. Pantopra-
zole, another proton-pump inhibitor, or H2 blockers
are reasonable to start on admission or per orated
peptic ulcer disease but long-term treatment is not
absolutely necessary, especially af er treatment or
H. Pylori. reatment o H. Pylori with a course o
antibiotics but chronic suppression should not be
necessary. Serum gastrin level can be checked or a
patients who is suspected o gastrinoma but is not
necessary i the patients peptic ulcer is healed.
BIBLIOGRPAHY
Baker RJ, T e Per orated Duodenal Ulcer. In: Fischer JE,
Jones DB, Pomposelli FB, Upchurch GR Jr., Klimberg VS,
Schwaitzberg SD, et al. Fischers Masters of Surgery. 5th ed.
Philadelphia, PA: Lippincott Williams & Wilkins; 2007:
891901.
Bertle MJ, Per orated peptic ulcer disease: a review o his-
tory and treatment. Dig Surg. 2010:1619.
Bhogal RH, Comparison between open and laparoscopic repair
o per orated peptic ulcer disease. World J Surg. 2008:23714.
Donovan AJ, Berne V, Donovan JA. Per orated duodenal
ulcer: an alternative therapeutic plan. Arch Surg. 1998;
133(11):116671.
Gusta son J,Welling D. No Acid, No Ulcer100 Years Later: A
review o the history o peptic ulcer disease. J Amer Coll
Surgeons. 2010:11017.
Jones DB, Mathiel SK, Schneider BE. Laparoscopic anagement
o peptic ulcer disease, atlas o minimally invasive surgery,
2006:196225.
Lin H and Jones DB, Surgery or Peptic Ulcer Disease, In alley
et al Practical Gastroenterology and Hepatology: Esopha-
gus and Stomach, Blackwell Publishing; 2010:404411.
Napolitano L. Re ractory peptic ulcer disease. Gastroenterol
Clin N Am. 2009; 38:26788.
Stabile BE.Rede ning the Role o Surgery or Per orated Duode-
nal Ulcer in the Helicobacter pylori Era. Ann Surg. Feb 2000;
231(2):15960.
 28
Marginal Ulcers

Richard M. Peterson

A 51-year-old emale presents to the emergency depart- 1. Which of the following is a factor that is potentially
ment. She complains o abdominal pain that has gotten contributing to this patients current problem?
worse over the last several days. T e pain is sharp and A. Hypercholesterolemia
located right under her breast bone. It seems to hap- B. Active smoking
pen right a er she eats or drinks and this morning it C. Obstructive sleep apnea
doubled her over. She relates that she has had this eeling D. Increase in carbohydrate intake
be ore, but it was never this bad. She has some nausea E. Age > 50
but no vomiting. Past medical history is signi cant or
hypertension, obstructive sleep apnea on CPAP, hyper- 2. Which of the following is the most common
cholesteremia, and type 2 diabetes (which she states has complication (early or late) following laparoscopic
been normal since her one month post op visit). Her gastric bypass?
surgical history is signi cant or one C-section about A. Internal hernias
15 years ago and a laparoscopic gastric bypass 9 months B. Small bowel obstruction
ago. She denies any drug use. She drinks a glass o red C. Marginal ulceration (anastomotic/gastro-jejunal
wine most evenings to help her heart. A er much ulcer)
probing she relates that even though she quit smoking D. Gastrojejunal leak
6 months prior to surgery, she resumed smoking about
6 months ago and is back up to one pack per day. She 3. Which of the following statements is true with
relates that at the time o her surgery she weighed 345 regards to marginal ulcer following gastric bypass?
lbs with a BMI o 59 kg/m 2 and now has lost 120 lbs A. Most marginal ulcers are asymptomatic.
with a BMI o 38.6 kg/m 2. She hasnt seen a bariatric B. Over one-third o patients with marginal ulcer
surgeon since her 3 month postoperative visit, mostly ormation smoke.
because she is embarrassed that she started smoking C. Active H. pylori in ection is an independent risk
again. She stopped taking her omeprazole 4 months ago actor or ulcer per oration.
when her prescription ran out. She also started taking D. Use o proton pump inhibitors is not protective
81 mg aspirin a er watching a documentary on heart o ulcer ormation in the setting o nonsteroidal
disease and obesity. anti-inf ammatory drugs (NSAID) use.
Vital signs are: HR 115, BP 97/62, RR 18, Pulse Ox 98% E. Suture material or type o anastomosis per-
on RA. Her exam is noted to have di use abdominal ten- ormed does not relate to ulcer ormation.
derness, signi cant tenderness in the epigastrium, with
voluntary guarding. Bowel sounds are absent. Hemoc-
cult testing is positive.

http://surgerybook.net/

4. Regarding treatment of marginal ulcers (MU)
following gastric bypass:
A. T e majority can be success ully managed medi-
cally.
B. Nearly hal o patients will require revision o the
gastrojejunostomy or persistent and/or recur-
rent ulcers.
C. Late MU are sel -limiting and rarely require
treatment.
D. H. pylori in ection pre-operatively or persistence
postoperatively increases per oration rates.
E. Endoscopy is o limited value in the treatment o
marginal ulcer.
5. Which of the following is true regarding
perforated marginal ulcers following gastric
bypass:
A. About 40% o patients with marginal ulceration
will develop a per oration.
B. May be managed operatively (open or laparo-
scopically) with oversewing o the ulcer and
omental patch.
C. Most commonly occurs a er 18 months rom
surgery.
D. Develops in about 10% o all patients that
undergo gastric bypass.
ANSWERS
1. B. T is patient most likely has a marginal ulcer,
which, at a rate o about 5% a er Roux-en-Y gastric
bypass, is one o the more common complications.
Risk actors associated with the development o
marginal (gastrojejunal/anastomotic) ulcers include
environmental (smoking and alcohol), medication
(NSAIDs), anatomical (gastro-gastric stula or an
enlarged gastric pouch), and technique (use o non-
absorbable sutures). T ere is no link associated with
speci c ood types and ulcer ormation. Other risk
actors that are associated with marginal ulcer (MU)
are increased acid exposure via a gastro-gastric s-
tula (not con rmed in this patient but more com-
monly seen with patients that have had an open
gastric bypass versus laparoscopic), hypertension,
and use o non-absorbable suture in the anastomosis
and recent surgery.
2. C. Marginal ulcers are a late complication o gas-
tric bypass surgery. Along with gastrojejunostomy
(GJ) stricture they are one o the most common
http://surgerybook.net/
C H AP TER 2 8 MARg i n Al U l C ERs 101
complications (early or late) o gastric bypass sur-
gery. Reported rates o MU range rom 1% to 25%,
with most series indicating 5% incidence. GJ stric-
ture rates are reported between 3% to 27%. T e
incidence o internal hernia a er gastric bypass is
nearly non-existent in the open gastric bypass, but
a er laparoscopic gastric bypass occurs in approxi-
mately 2.5% o patients. Small bowel obstruction is
linked to internal hernia ormation and the rates are
equivalent. GJ leaks are an early complication a er
gastric bypass. In the laparoscopic approach, rates are
reported at about 1% to 1.8%.
3. B. O patients presenting with MU, over 30% are
ound to be smoking at the time o diagnosis. Most
MU are symptomatic (72%). T ose symptoms that
are most common a er surgery that lead to the
diagnosis o MU are: pain (34%), dysphagia (17%),
weight gain (13%), nausea and vomiting (8%), and
GI bleed (3%). Active H. pylori in ection has not
been determined to be an independent risk actor in
the development o per orated MU. T ere is data that
suggests that in the setting o patients that must use
NSAIDs ollowing gastric bypass that proton pump
inhibitors (PPIs) are protective o MU ormation.
While there is still debate as to whether hand-sewn
gastrojejunostomy (GJ) versus stapled anastomosis is
better with relationship to post operative outcomes,
the data clearly relates that non-absorbable suture
material at the anastomosis has a high association
with MU ormation. Because o this act, the use o
non-absorbable suture at the GJ anastomosis has
essentially ceased.
4. A. T e treatment o MU is largely medical. T e
standard o treatment is PPI therapy initiation/
continuation and cytoprotective agents (i.e., sucral-
ate or cara ate). Additionally cessation o smoking
and/or NSAID use is critical, as recurrence is high
in patients that continue with these high level risk
actors. Studies report the incidence o surgical
intervention or MU to be 4% to 10%. T is usually
occurs in this subset o MU or recalcitrant and/or
recurrent ulcers. Continued smoking and NSAID
use were ound to be independent risk actors or
continued non-healing ulcers. Late ulcers (those
that occur a er 30 days) are rarely sel -limiting. In a
study by Csendes they did a prospective evaluation
o patients and per ormed endoscopy at 1 month
and at 1 to 2 years. T ey ound a 12% rate o MU
102 g En ERAl s U Rg ERY EXAM i n ATi O n An D BO ARD REVi EW
at 1 month. Many authors believe this to be part o
the natural progression and healing process o the
anastomosis within such a short time rame. Most
clinicians advocate or PPI use in the immedi-
ate postoperative period because o this. Clinically
apparent MU is unlikely to heal without interven-
tion (as mentioned above). While the data is not
completely clear about the role o H. pylori in ec-
tion and ulcer ormation, the risk o per oration o
MU is not increased by the presence o H. pylori.
One study ound that in patients that were H. pylori
positive and eradicated prior to surgery, the rate o
MU a er surgery with short term PPI use was sig-
ni cantly reduced. Endoscopy should be part o the
armamentarium o diagnosing and treating MU.
5. B. Most ulcers become apparent within the rst
12 months ollowing surgery. While they can develop
beyond 18 months ollowing surgery this is not the
most common time rame that they are seen. T e inci-
dence o per oration in all patients undergoing lapa-
roscopic gastric bypass is approximately 1% and the
incidence o MU on average is 5% (range 1% to 16%),
there ore the rate o per oration o MU is 20%. Felix
et al. in 2008 ound that many cases could be man-
aged laparoscopically. In their series, over 30% were
managed by oversewing o the ulcer and utilizing an
omental patch. Other series have con rmed similar
treatment strategies or MU per oration utilizing the
omental patch. imes when it may be necessary or
more appropriate to consider revising the G-J may
include MU with bleeding, with or without per ora-
tion; recurrent ulceration, when a gastro-gastric s-
tula is present; or when the pouch is greatly enlarged.
BIBLIOGRAPHY
Azagury DE, Abu Dayyeh BK, Greenwalt I , T ompson CC.
Marginal ulceration a er Roux-en-Y gastric bypass sur-
gery: Characteristics, risk actors, treatment, and outcomes.
Endoscopy. 2011;43(11):9504.
http://surgerybook.net/
Bhayani NH, Oyetunji A, Chang DA, et al. Predictors o
marginal ulcers a er laparoscopic gastric Roux-en-Y gas-
tric bypass. J Surg Res. 2012;177(2):2247.
Coblijn UK, Goucham AB, Lagarde SM, Kuiken SD, van
Wagensveld BA. Development o ulcer disease a er
Roux-en-Y gastric bypass, incidence, risk actors, and
patient presentation: a systematic review. Obes Surg. 2014;
24(2):299309.
Coblijn UK, Lagarde SM, de Castro SMM, Kuiken SD, van
Wagensveld BA. Symptomatic marginal ulcer disease a er
Roux-en-Y gastric bypass: Incidence, risk actors and man-
agement. Obes Surg. 2015;25:80511.
Csendes A, Burgos AM, Altuve J, Bonacic S. Incidence o
marginal ulcer 1 month and 1 to 2 years a er gastric
bypass: A prospective consecutive endoscopic evaluation
o 442 patients with morbid obesity. Obes Surg. 2009;19:
1358.
DHondt MA, Pottel H, Devriendt D, Van Rooy F, Vansteen-
kiste F. Can a short course o prophylactic low-dose pro-
ton pump inhibitor therapy prevent stomal ulceration
a er laparoscopic Roux-en-Y gastric bypass? Obes Surg.
2010;20:5 9599.
Eckhauser A, ourquati A, Yousse Y, et al. Internal hernia:
postoperative complication o roux-en-Y gastric bypass
surgery. Am Surg. 2006;72(7):58184.
El-Hayek K, imratana P, Shimizu H, Chand B. Marginal
ulcer a er Roux-en-Y gastric bypass: what have we really
learned? Surg Endosc. 2012;26:278996.
Felix EL, Kettelle J, Mobley E, Swartz D. Per orated mar-
ginal ulcers a er laparoscopic gastric bypass. Surg Endosc.
2008;22:212832.
Ibele AR, Bendewald FP, Mattar SG, McKenna D . Incidence
o gastrojejunostomy stricture in laparoscopic Roux-en-Y
gastric bypass using an autologous brin sealant. Obes
Surg. 2014; Mar 6 [Epub ahead o print].
Kalaiselvan R, Exarchos G, Hamza N, Ammori BJ. Incidence
o per orated gastrojejunal anastomotic ulcers a er lapa-
roscopic gastric bypass or morbid obesity and role o
laparoscopy in their management. Surg Obes Relat Dis.
2012;8(4):4238.
Yurcisin BM, DeMaria EJ. Management o leak in the bariatric
gastric bypass patient: Re-operate, drain, and eed distally.
J Gastrointest Surg. 2009;13:156466.
Wilson JA, Romagnuolo J, Byrne K, et al. Predictors o endo-
scopic ndings a er Roux-en-Y gastric bypass. Am J Gas-
troenterol. 2006;101(10):21949.
 29
Bariatric SurgeryBypass
Abdominal Pain
Richard M. Peterson
A 37-year-old emale presents to the emergency depart-
ment. She complains o abdominal pain that awoke
her rom sleep and has been persistent over the last
34 hours. She cant get com ortable, is experiencing
nausea, and some emesis. She relates that she has had
similar episodes in the past couple o months about 1 to
2 times per week, but it was usually sel -limited, but this
is the worst she has elt. Her surgical history is signi -
cant or two C-sections about 4 and 6 years ago, a laparo-
scopic gastric bypass a little over 2 years ago, and an open
appendectomy when she was 12. She denies any drug use,
alcohol use, or smoking. She relates that at the time o
her surgery she weighed 290 lbs with a BMI o 53 kg/m 2
and now has lost 155 lbs with a BMI o 24.7 kg/m 2. She
hasnt seen a bariatric surgeon in over a year since she
just moved here or her new job 11 months ago.
Vital signs are: HR 102, BP 138/67, RR 20, Pulse Ox
99% on RA. Her exam is noted to have di use abdomi-
nal tenderness, with the area tender in the mid abdo-
men. Bowel sounds are present and high-pitched.
1. Which o the ollowing would is the next most
appropriate step in this patients management?
A. Upper endoscopy (EGD)
B. Nasogastric tube decompression
C. Abdominal X-ray
D. C scan o abdomen and pelvis
2. Which o the ollowing statements is true regarding
laparoscopic gastric bypass?
A. Internal hernias a er laparoscopic gastric bypass
are ar less common than those seen with open
gastric bypass.
http://surgerybook.net/
B. Small bowel obstruction a er laparoscopic gas-
tric bypass can be conservatively managed in
about 80% o cases.
C. Intusseption at the jejunojejunostomy (JJ) can be
a source o abdominal pain.
D. A dilated gastric remnant is a normal nding on
C scan in post gastric bypass patients.
E. Large de ects like the Petersens hernia as seen in
a retrocolic gastric bypass do not need de nitive
closure.
3. Small bowel obstruction a er a laparoscopic
gastric bypass:
A. Requires emergent exploration.
B. Can be managed conservatively in 80% o cases.
C. Is o en caused by adhesions rom the original
surgery.
D. Should never be evaluated laparoscopically.
4. T e most common cause o abdominal pain a er
an Roux-en-Y gastric bypass (RYGB) is?
A. Internal hernia causing a small bowel obstruc-
tion
B. Marginal ulcer (ulcer at the gastrojejunostomy)
C. Gastrojejunostomy stricture
D. Intussusception o the jejunojejunostomy
E. Biliary colic or dyskinesia
5. When evaluating a patient or intermittent
abdominal pain in your of ce a er laparoscopic
gastric bypass:
A. UGI should be considered to evaluate or mar-
ginal ulcer.
10 4 G EN ERAL S U RG ERY EXAM I N ATI O N AN D BO ARD REVIEW
B. C scan should be per ormed to de nitively rule
out an internal hernia.
C. T e patient should be o ered psychological
counseling since most pain a er a laparoscopic
gastric bypass is psychosomatic.
D. Diagnostic laparoscopy should be considered to
evaluate or potential sources o internal hernia.
ANSWERS
1. D. In this scenario, nasogastric tube (NG ) decom-
pression is insu cient to treat a patient that has
had a gastric bypass and bowel obstruction. T ese
patients require an operative intervention as con-
servative management can have catastrophic conse-
quences. Bowel obstruction a er laparoscopic gastric
bypass is o en associated with an internal hernia. In
the setting o an open gastric bypass the obstruction
is more likely adhesions versus an internal hernia
(typically less adhesion ormation a er laparoscopic
gastric bypass). Conservative management o bowel
obstruction a er gastric bypass can be dangerous as
the bowel will need to be manually decompressed
and conservative management is rarely success ul.
T e rate o internal hernia a er laparoscopic gastric
bypass is about 2.5% with studies ranging between
0.2% to 8%.
Re tro c o lic and ante c o lic pathways o f the Ro ux limb
3 obstruction that can lead to gastric remnant dilation.
1 1
2 2
Re trocolic Ante colic
Intravenous hydration is appropriate as patients
with bowel obstruction can requently be dehydrated.
An abdominal X-ray may provide some in ormation
and is a quick test. Air f uid levels may be seen or air
in the gastric remnant can indicate an obstruction,
but they are most o en non-speci c. A C scan o en
can provide the in ormation relating to the source o
the bowel obstruction. In patients with active (acute)
symptoms o bowel obstruction a er gastric bypass
and undergoing a C scan, swirling o the mesentery
http://surgerybook.net/
is the most sensitive indicator seen and is associated
with an internal hernia. Up to 20% o cases can be
missed on C scan. Intermittent (chronic) symptoms
o bowel obstruction may not show signs o an inter-
nal hernia on a C scan and there ore the clinical
impression may lead to a diagnostic laparoscopy or
evaluation o potential hernia de ects (these are com-
monly ound at the JJ mesenteric de ect or the retro-
roux limb (Petersens hernia) de ect).
2. C. Intussusception o the JJ can lead to chronic
intermittent abdominal pain. Possible causes o
intussusception can be related to stricture o the JJ
or a dilated JJ pouch, either o which can serve as a
lead point during peristalsis and subsequent intus-
susception. Internal hernia a er laparoscopic gastric
bypass are more common than open gastric bypass
(this relates to more adhesions in the open gastric
bypass and hence greater likelihood o the closure o
the potential spaces by adhesion ormation). Small
bowel obstruction a er laparoscopic gastric bypass
is rarely success ully managed conservatively, with
most cases requiring operative intervention. Delay in
getting to the operating room can lead to signi cant
loss o small bowel. A dilated gastric remnant is not
a normal nding on a C scan a er gastric bypass.
A dilated remnant strongly suggests obstruction o
the biliopancreatic limb. Stricture o the JJ, intussus-
ception o the JJ, or internal hernia are all sources o
Petersens hernia in a retrocolic gastric bypass is a
small de ect and there ore must be closed. T e small
size o the de ect can lead to incarceration and stran-
gulation o bowel. T ere are also reported cases o
strangulation o bowel in the Petersens hernia o an
antecolic gastric bypass, but this space is larger and
there ore theoretically less likely to have strangula-
tion o bowel.
3. A. Small bowel obstruction a er laparoscopic gas-
tric bypass requires emergent exploration. T e most
likely source is an internal hernia either occurring at
the JJ mesenteric de ect (50% to 62%) the transverse
mesocolon (23% to 46%) or the Petersens hernia
(12% to 15%). Most surgeons close these de ects at
the time o surgery, but as patients lose weight (esti-
mated greatest incidence a er > 50% o excess weight
lost) or other sources o increased intra-abdominal
pressure such as pregnancy with an enlarged uterus
can lead to a weakening o the original repair. Bowel
 C H AP TER 2 9 BARI ATRI C S U RG ERY BYPAS S ABD O M IN AL PAI N
obstruction secondary to adhesions a er laparo-
scopic gastric bypass is airly uncommon. Small
bowel obstruction even in non-bariatric surgery cases
reportedly is non-operatively managed in about 40%
o cases. Laparoscopic evaluation o internal hernia
a er laparoscopic gastric bypass is well documented
and sa e. T e clinicians com ort with laparoscopy
versus open surgery should be the de ning actor
regarding exploration as either can provide good
outcomes. T e key component is de ning the anat-
omy. It is recommended that reduction o the inter-
nal hernia begin with identi cation o the ileocecal
valve and ollowing the bowel proximally. T is will
serve to both reduce the hernia on the appropriate
side o the de ect and will acilitate the identi cation
o the anatomic landmarks o the JJ, biliopancreatic
limb, and Roux limb.
4. A. Internal hernia is o en associated with pain, with
or without nausea and emesis. T is can be acute onset
or it can be intermittent and chronic warranting ur-
ther workup and ultimately surgical intervention. It
is the most common cause o abdominal pain a er
RYGB. Symptoms o a gastrojejunostomy stricture
are rarely related to pain. T e most common pres-
entations are dysphagia and ood intolerance. T ese
symptoms typically occur about 6 to 8 weeks ollow-
ing surgery with a gradual regression o ood toler-
ance rom having been advanced to solid oods and
then noting di culty, ollowed by inability to toler-
ate solids and only able to tolerate liquids. Marginal
ulcer ollowing gastric bypass is also associated with
pain. T is usually occurs immediately a er eating
or drinking. Risk actors or developing a marginal
ulcer are use o NSAIDs, smoking, gastro-gastric s-
tula ormation, and oreign body (i.e., suture/staple).
Intussusception also presents with pain and is
similar to that o an internal hernia. It is commonly
intermittent and o en unseen on C scan unless
the event is occurring during the imaging study. Bil-
iary colic or dyskinesia is also source o abdominal
pain ollowing weight loss surgery. Gallstone orma-
tion occurs as a result o rapid weight loss and may
become symptomatic. A standard o practice is not
to remove the gallbladder at the time o laparoscopic
gastric bypass. T e incidence o symptomatic gall-
stone ormation a er surgery approaches 8%. In the
study by Caruana et al. (Surg Obes Relat Dis. 2005;
1(6):5647), they also determined that it was not cost
http://surgerybook.net/
10 5
e ective to utilize ursodeoxycholic acid (Ursodiol) as
a prophylactic treatment modality or gallstone or-
mation prevention.
5. D. Patients that present with abdominal pain a er
laparoscopic gastric bypass warrant a ull evalua-
tion. It is rarely a psychological source and as such
appropriate history should be taken. I the patient
still has complaints o abdominal pain a er a nega-
tive ull evaluation, including upper endoscopy to
rule out gastrojejunal ulcer, gastro-gastric stula, a
C scan, colonoscopy to rule out a colonic source,
a right upper quadrant ultrasound to rule out gall-
stone diseases and a HIDA scan to rule out biliary
dyskinesia, then diagnostic laparoscopy is the next
step in management. Since upwards o 20% o C
scans will not have evidence o an internal hernia,
visual evaluation o the potential internal hernia
spaces is imperative. Postoperative internal her-
nia ormation occurs in approximately 2.5% o
patients, with approximately 50% to 60% o hernias
at the JJ mesenteric de ect, 20% at the transverse
mesocolon mesentery and 12% to 15% o hernias
at the Petersens hernia. An upper GI f uoroscopic
study may provide in ormation about pouch size,
absence or presence o a hiatal hernia, stricture and
sometimes ulcer, however, it is not a rst choice or
evaluation. Given the higher speci city o an EGD
evaluation, this study would yield ar less in orma-
tion in lieu o the other choices o ered.
BIBLIOGRAPHY
Ahmed AR, Rickards G, Husain S, et al. rends in internal
hernia a er laparoscopic Roux-en-Y gastric bypass. Obes
Surg. 2007;17(12):15636.
Caruana JA, McCabe MN, Smith AD, et al. Incidence o
symptomatic gallstones a er gastric bypass: is prophy-
lactic treatment really necessary? Surg Obes Relat Dis.
2005;1(6):5647.
Eckhauser A, ourquati A, Yousse Y, et al. Internal hernia:
postoperative complication o roux-en-Y gastric bypass
surgery. Am Surg. 2006;72(7):5814.
Obeid A, McNeal S, Breland M, et al. Internal hernia a er
laparoscopic Roux-en-Y gastric bypass. J Gastrointest Surg.
2014;18(2):2505.
Schirmer BD. Strictures and Marginal Ulcers in Bariatric
Surgery. In Buchwald H, Cowan GH, Pories WJ. Surgical
Management of Obesity. 1st ed. Philadelphia, PA: Saunders
Elsevier: 2007:297303.
Williams SB, Greenspon J, Young HA, et al. Small bowel
obstruction: conservative vs. surgical management. Dis Col
Rectum. 2005;48(6):114046.
 30
Sleeve Gastrectomy Leaks
Alec C. Beekley
A 42-year-old emale with a body mass index o
42 kg/m 2 along with diabetes mellitus, hypertension,
hyperlipidemia, and obstructive sleep apnea (OSA)
has completed her preoperative evaluation or sur-
gical management o her obesity and weight related
co-morbidities. She uses Continuous Positive Airway
Pressure (CPAP) nightly or her OSA. She is elt to be
a good candidate or surgery and she opted or a Sleeve
Gastrectomy (SG).
1. Regarding the immediate postoperative manage-
ment, which o the ollowing is correct?
A. Use o CPAP is contraindicated or the rst post-
operative week or ear o it causing a leak.
B. Sustained tachycardia is the most reliable indica-
tor o a leak.
C. T e most likely cause o death a er bariatric sur-
gery is a myocardial in arction.
D. T is patient should have had an IVC lter to pre-
vent a pulmonary embolus.
E. T e leak rate rom a SG is less than that o a
Roux-en-Y gastric bypass (RYGB).
2. Regarding intra-operative actors that a ect
staple line leaks af er SG, which o the ollowing is
correct?
A. Staple line buttressing has conclusively shown to
decrease the incidence o staple line leak.
B. Over-sewing o the staple line has been shown to
decrease the incidence o staple line leak.
C. Per ormance o sleeve gastrectomy over a smaller
diameter bougie decreases the likelihood o sta-
ple line leak.
http://surgerybook.net/
D. reatment o the staple line with brin glue has
been shown to decrease the staple line leak rate.
E. Choice o staple height does not have an e ect on
staple line leak rates.
3. T e patient presents with ever, abdominal pain,
and sustained tachycardia on post operative day 4.
Which o the ollowing is correct?
A. A normal upper gastrointestinal contrast series
rules out a staple line leak.
B. Operative management o a staple line leak is
more likely to be success ul in this patient than
in patients whose leaks present 10 days or more
a er operation.
C. I a closed suction drain is le at the initial oper-
ation and the drain amylase level is the same
as the serum amylase level, this nding reliably
rules out a staple line leak.
D. A positive preoperative H. Pylori test increased
this patients chance o having a staple line leak.
E. Endoscopic therapies should be the rst
approach to gain control o a staple line leak.
4. T e patient undergoes operative repair o the
staple line leak on postoperative day 4. A closed
suction drain is lef . Which o the ollowing is
correct?
A. I this patient develops a gastro-cutaneous s-
tula controlled by the closed suction drain,
endoscopic treatment with a covered stent, clip-
ping, and/or brin glue should be considered an
experimental option and discouraged unless the
patients condition is severe.

B. T e median time or staple line leaks to heal is
less than 2 weeks.
C. I an endoscopic stent is placed across the leak,
the biggest problem that can occur is stent ero-
sion.
D. I the patient develops a controlled gastro-
cutaneous stula, drainage alone is still an
acceptable option or treatment.
E. Chronic leaks/ stulae can be managed with late
surgical therapy, such as Roux-en-Y anastomosis
to the stula site.
5. Which o the ollowing is correct regarding staple
line leaks af er sleeve gastrectomy?
A. Leaks > 10 days a er operation are more likely
to occur a er gastric bypass than sleeve gastrec-
tomy.
B. Leaks most commonly occur in the distal third
or antral staple lines.
C. Patients whose sleeve leaks are treated by endo-
scopic stenting still must be restricted rom tak-
ing nutrition by mouth until the leak heals.
D. Non-operative management o leaks is unac-
ceptable in any sleeve patient.
E. Patients with stulae that ail to close may require
conversion to gastric bypass or gastrectomy.
ANSWERS
1. B. Sustained tachycardia greater than 120 is the
most reliable indicator o a postoperative leak rom
bariatric surgery. Other complications that can lead
to tachycardia like myocardial in arction, pulmonary
embolism, bleeding, hypovolemia, and respiratory
insu ciency should also be ruled out but unex-
plained and sustained tachycardia should prompt an
intervention to nd and treat a leak, which includes
operative exploration. T e leak rate o a SG (2.4%) is
higher than that o a RYGB (0.8%).
CPAP is not contraindicated a er a SG, or a
RYGB or that matter, and should plan to be used in
the postoperative period or people who su er rom
OSA. T ere is no data that suggests it increases the
risk o a leak. While people who have a respiratory
complication a er bariatric surgery are at an increase
risk o mortality, the most common cause o death
a er bariatric surgery is sepsis, ollowed by myocar-
dial in arction, then a pulmonary embolism.
T e recommended venous thromboembolic
(V E) prophylaxis or this patient is mechanical
http://surgerybook.net/
C H AP TER 3 0 S l EEv E G AS TREC To m y l EAk S 107
prophylaxis, ambulation on the night a er surgery,
and chemical prophylaxis with low molecular weight
heparin or un ractionated heparin. T ere is no abso-
lute indication or preoperative IVC lter placement
but it can be considered, along with mechanical and
chemical prophylaxis in high risk patients, especially
i the risk o a V E is higher than that o a lter
related complication.
2. E. Multiple intra-operative techniques have been
employed and studied to attempt to reduce staple line
leak rates a er sleeve gastrectomy. Although there is
some evidence that the use o buttressing material
can reduce bleeding rom the staple line, there are no
conclusive data that staple line leak rates are reduced.
Similarly, choice o staple height and over sewing o
the staple line did not show any bene t in reducing
staple line leak.
T e use o a bougie > 40 French in diameter has
been shown to decrease the leak rate without a dis-
cernible impact on weight loss at up to 3 years com-
pared to smaller bougies (< 40 French). Distance
rom pylorus that the staple line was begun also did
not a ect leak rates. Finally, treatment o the staple
line with brin glue did not conclusively demon-
strate any bene t in reducing staple line leak in gas-
tric bypass patients and little data exist to suggest it
has any bene t in sleeve gastrectomy patients.
3. B. Staple line leaks a er sleeve gastrectomy present
challenging problems in terms o both diagnosis and
management. Surgical treatment o staple line leaks
that occur early (< 10 days) a er operation are more
likely to be success ul than surgical treatment o late
(> 10 days) leaks. Although clinical signs can be sub-
tle, upper gastrointestinal (UGI) series have been
noted to be unreliable. Closed suction drain amylase
has been suggested as a reasonable adjunct to clinical
suspicion o a leak, but patients with leaks and normal
drain amylase levels have been demonstrated. T ere-
ore, a normal drain amylase or a negative UGI should
not prevent a surgeon rom returning a patient to the
OR i clinical suspicion or a leak remains.
Although pre-operative detection and eradica-
tion o H. Pylori in ections has been advocated to
reduce post operative dyspepsia or ulceration, the
presence o H. Pylori does not appear to impact sta-
ple line leak rates. Although endoscopic therapies
provide a use ul adjunct in the treatment o gastric
sleeve staple line leaks, they generally should not be
10 8 G EN ERAl S U RG ERy EXAm I N ATIo N AN D Bo ARD REv I EW
used as the initial or primary therapy. Resuscitation,
intravenous hydration and antibiotics, and either
early surgical or interventional radiologic drainage
o intra-abdominal f uid collections to control sepsis
should be rst line therapies.
4. E. One o the largest reviews o staple line leaks a er
sleeve gastrectomy demonstrated that the median
time or leak healing was 40 days (range 2 to 270).
Endoluminal therapies or staple line leaks show a
airly high rate o success at resolving leaks and s-
tulas, with the main problem being stent migration.
Although endoluminal therapies are use ul adjuncts,
standard stula management with drainage is still an
acceptable option but it also mandates nutritional
support. Chronic stulae that develop can be suc-
cess ully managed by late surgical therapy.
5. E. Late leaks (> 10 days a er initial surgery) are more
likely to occur in sleeve gastrectomy patients than in
gastric bypass patients. T e majority (89%) o leaks
occur in the proximal third o the stomach. Non-
surgical therapy is clearly an appropriate option in
selected patients with leak, and endoluminal stenting
has the speci c advantage o allowing patients to take
ood by mouth. otal gastrectomy with esophagoje-
junostomy, conversion to gastric bypass, and lateral
Roux-en-Y gastrojejunostomy all have been described
as surgical therapy or sleeve stulae that ail to heal.
BIBLIOGRAPHY
Aurora AR, Khaitan L, Saber AA. Sleeve gastrectomy and the
risk o leak: a systematic analysis o 4,888 patients. Surg
Endosc. June 2012;26(6):150915.
Brethauer SA, et al. and the American Society o Metabolic
and Bariatric Surgery Clinical Issues Committee. ASMBS
updated position statement on prophylactic measures to
reduce the risk o venous thromboembolism in bariatric
surgery. SOARD. 2013;9(4):4937.
Casella G, Soricelli E, Rizzello M, rentino P, Fiocca F,
Fantini A, et al. Nonsurgical treatment o staple line leaks
http://surgerybook.net/
a er laparoscopic sleeve gastrectomy. Obes Surg. July 2009;
19(7):8216.
Chen BI, Kiriakopoulos A, sakayannis D, Wachtel MS,
Linos D, Frezza EE. Rein orcement does not necessarily
reduce the rate o staple line leaks a er sleeve gastrectomy.
A review o the literature and clinical experiences. Obes
Surg. February 2009;19(2):16672.
Gaspari A, Gentileschi P, acchino R, Basso N. T e use o brin
sealant to prevent major complications ollowing laparo-
scopic gastric bypass: results o a multicenter, randomized
trial. Surg Endosc. November 2008;22(11):24927.
Gupta PK, et al. Predictors o pulmonary complications a er
bariatric surgery. SOARD. 2012;8:57481.
Maher JW, Bakhos W, Nahmias N, Wol e LG, Meador JG,
Baugh N, et al. Drain amylase levels are an adjunct in
detection o gastrojejunostomy leaks a er Roux-en-Y
gastric bypass. J Am Coll Surg. May 2009;208(5):8814;
discussion 8856.
Nelson DW, Blair KS, Martin MJ. Analysis o obesity-related
outcomes and bariatric ailure rates with the duodenal
switch v gastric bypass or morbid obesity. Arch Surg. 2012;
147(9):84754.
Parikh MI, Issa R, McCrillis A, Saunders JK, Ude-Welcome A,
Gagner M. Surgical strategies that may decrease leak
a er laparoscopic sleeve gastrectomy: a systematic review
and meta-analysis o 9991 cases. Ann Surg. 2013;257(2):
2317.
Rossetti G, et al. Does helicobacter pylori in ection have inf u-
ence on outcome o laparoscopic sleeve gastrectomy or
morbid obesity? Int J Surg. 2014;12 Suppl 1:S6871.
Silecchia GI, Boru CE, Mouiel J, Rossi M, Anselmino M,
Morino M, et al. Utility o routine versus selective upper
gastrointestinal series to detect anastomotic leaks a er
laparoscopic gastric bypass. Obes Surg. August 2011;21(8):
123842.
T aler K. reatment o leaks and other bariatric complications
with endoluminal stents. J Gastrointest Surg. September
2009;13(9):15679.
Sakran N, et al. Gastric leaks a er sleeve gastrectomy; a multi-
center experience with 2834 patients. Surg Endosc. January
2013;27(1):2405.
van de Vrande S, Himpens J, EI Mourad H, Debaerdemaeker
R, Leman G. Management o chronic proximal stu-
las a er sleeve gastrectomy by laparoscopic Roux-limb
placement. Surg Obes Relat Dis. November-December
2013;9(6):85661.
 31
Biliopancreatic Diversion
With Duodenal Switch or
Morbid Obesity
Matthew J. Martin
A 34-year-old morbidly obese emale with a current body
mass index (BMI) o 55 kg/m2 is being evaluated or poten-
tial bariatric surgery. She has tried numerous diet and
exercise programs, including a medically supervised pro-
gram or 12 months and has ailed to maintain any signi -
cant weight loss. She has type 2 diabetes, gastroesophageal
re ux disease (GERD), hypertension, and sleep apnea. She
has had two prior c-sections and a laparoscopic cholecys-
tectomy but no other surgeries. She has done independent
research on the internet and is interested in getting more
in ormation about the duodenal switch procedure.
1. Which o the ollowing statements about bariatric
surgical procedures is correct?
A. All true bariatric surgery achieves weight loss
through restrictive e ects and malabsorptive
e ects.
B. T e duodenal switch is the most malabsorptive
o the currently per ormed bariatric procedures.
C. T e duodenal switch is the most restrictive o the
currently per ormed procedures.
D. Candidates or the duodenal switch must have a
body mass index above 55 kg/m 2.
E. T is patients medical comorbidities disquali es
her or bariatric surgery.
2. T e patient is con used about the anatomic
di erence between the duodenal switch and the
gastric bypass. Which o the ollowing statements
is correct about the duodenal switch versus gastric
bypass anatomy?
A. Both the duodenal switch and the gastric bypass
involve the creation o a small proximal gastric pouch.
http://surgerybook.net/
B. T e duodenal switch involves a sleeve gastrec-
tomy and preservation o the pylorus.
C. T e duodenal switch creates less bypassed
intestine than the gastric bypass, resulting in less
malabsorption.
D. T e alimentary limb o the small intestine is
anastomosed to the stomach in both operations.
E. T e amount o malabsorption with the duodenal
switch is primarily a unction o the length o the
biliopancreatic limb.
3. T e patient is interested in knowing about the
potential benef ts o surgery, and whether she is a
candidate or a laparoscopic or open surgery. Which
o the ollowing statements are correct regarding
the duodenal switch?
A. T e patient is not a candidate or a laparoscopic
approach due to her prior abdominal surgery.
B. T e surgery has a 50% chance o improving her
diabetes, but only af er she has achieved signi -
cant weight loss.
C. T e surgery has a near 100% likelihood o curing
her gastroesophageal re ux disease.
D. She can expect to lose 40% to 50% o her excess
body weight in the rst year af er surgery.
E. T e duodenal switch is associated with an 80% to
90% rate o resolution or her hypertension, sleep
apnea, and diabetes at one year af er surgery.
4. T e patient also wishes to know about the risks o
surgery and common complications associated
with the duodenal switch. Which o the ollowing
statements is correct?
110 G EN ERAL S U RG ERY EXAM IN ATIO N AN D BO ARD REVIEW
A. Unlike the gastric bypass, there is no postopera-
tive risk o an internal hernia af er the duodenal
switch procedure.
B. Chronic diarrhea and steatorrhea may be a com-
plication o this procedure.
C. Protein and calorie malabsorption, that requires
parenteral nutrition or surgical revision, only
occurs in less than 1% o patients.
D. Fat malabsorption may result in de ciencies o
vitamins B6 and C.
E. Symptoms o dumping syndrome af er a duode-
nal switch are likely.
5. T e patient undergoes an uncomplicated
laparoscopic duodenal switch procedure and is
discharged home on postoperative day 3. On post-
operative day 5 she presents to the emergency
department with worsening abdominal pain,
distension, evers, and emesis. She is ebrile to
102.7F, tachycardic to 125, tachypneic, and has
a systolic blood pressure o 80. Her abdomen
is di usely tender. She states that she has had
diarrhea or the past 3 days and has not been able
to tolerate oral intake. Which o the ollowing
statements about the evaluation and management
o this patient is correct?
A. Intravenous uid resuscitation should not be
given due to the concern or possible volume
overload and pulmonary edema.
B. A normal upper GI series with oral contrast
(swallow study) will rule out an abdominal
source o pathology.
C. An urgent C Pulmonary Angiogram must be
obtained to rule out a pulmonary embolus.
D. T e patient will likely require emergent surgical
exploration to identi y the cause o her symptoms.
E. T e most likely cause o her symptoms is an
internal hernia.
ANSWERS
1. B. All currently per ormed bariatric procedures
achieve weight loss primarily through either restric-
tion, malabsorption, or both. Restriction is achieved
by reducing the volume capacity o the stomach
through reduction in size or external compression.
T e Sleeve Gastrectomy and Adjustable Gastric Band
are the only endorsed restrictive procedures. Malab-
sorption is achieved through re-routing o the small
intestine and digestive enzymes to decrease the length
http://surgerybook.net/
o intestine available or absorption. T e duodenal
switch (also known as the biliopancreatic diversion
with duodenal switch) involves the longest length o
bypassed intestine, and thus is more malabsorptive
than other procedures such as the gastric bypass.
T e restrictive component o the duodenal switch
involves ormation o a gastric sleeve, which achieves
moderate restriction. Other procedures such as the
gastric bypass and adjustable gastric band are more
restrictive than the duodenal switch. Candidacy or
a duodenal switch is the same as or any bariatric
procedure (BMI > 40 or > 35 with obesity-related
co-morbidities), although most surgeons reserve
this option or higher BMI patients. Medical comor-
bidities related to obesity are not contra-indications
to surgery, and improvement or resolution o these
comorbidities is the primary goal o bariatric surgery.
2. B. T e gastric bypass involves creation o a small
proximal gastric pouch that is highly restrictive. In
contrast, the duodenal switch involves creation o a
vertical sleeve gastrectomy (see Figure 31-1) and divi-
sion o the duodenum just past the pylorus, resulting
in a greater gastric capacity and less restriction than
the gastric bypass. T e duodenal switch operation
preserves the pylorus and at least part o the antrum,
which provides the advantage o controlled gastric
emptying and avoidance o the dumping syndrome
that is requently seen with the gastric bypass. T e
duodenal switch results in MORE bypassed intestine
than the gastric bypass and is the most malabsorp-
tive bariatric procedure currently in use.
T e nal anatomy o the duodenal switch is as
shown in Figure 31-1: T e alimentary limb (AL,
and analogous to the roux limb in gastric bypass)
is typically 150 to 200 cm long and the proximal
end is anastomosed to the duodenum just past the
pylorus. T e biliopancreatic limb (BPL) is typically
long and unmeasured. T e small intestine distal to
the junction o the AL and BPL is called the com-
mon channel or common limb (CL), and is typically
50 to 150 cm in length rom the ileocecal valve. T e
amount o malabsorption is primarily a unction o
the length o the common channel, as this is where
nutrients are mixed with the biliopancreatic diges-
tive enzymes. A shorter common channel will result
in greater malabsorption, and vice-versa.
3. E. Among the currently per ormed bariatric pro-
cedures, the duodenal switch has been associ-
 C H AP TER 3 1 BI LI O PAN C REATI C D IVERS IO N WITH D U O D EN AL S WITC H f O R M O RBID O BES I T Y 111

Bilio panc re atic dive rs io n with duo de nal s witc h

Alime nta ry
limb
Biliopa ncre a tic
limb

Common cha nne l

Figure 31-1 Diagram o the duodenal switch anatomy including the ali-
mentary limb (AL), the biliopancreatic limb (BPL), and the common limb or
common channel (CL). Reprinted with permission (Gagner M et al. 2009).

ated with the greatest absolute and relative weight surgery, and prior pelvis or laparoscopic abdominal
loss (Figure 31-2), as well as the highest rates o surgery is not a contraindication to a laparoscopic
improvement or resolution o obesity-related comor- approach. T e duodenal switch has been reported to
bidities. T e duodenal switch can be per ormed as achieve an average 80% to 100% rate o improvement
an open or a laparoscopic procedure, although it is or resolution o type 2 diabetes and normalization o
arguably the most technically challenging bariatric HgBA1C levels (Figure 31-3).
procedure to per orm laparoscopically. T is patient
7
would be an excellent candidate or laparoscopic
Roux-e n-Y ga s tric bypa s s
n
i
b
o
l
6
g
Biliopa ncre a tic dive rs ion
o
m
RYGB Roux-e n-Y ga s tric bypa s s with duode na l switch
e
BP D/DS Biliopa ncre a tic dive rs ion with duode na l s witch
h
5
d
BPD/DS RYGB
e
t
a
0
l
o
yc
4
l
G
20
s
s
%
o
l
rs
-
3
I
a
M
40 a
r
ye
ye
B
ly 3
e 1
s
tiv
s
60 ra
e
e
xc
p
o
E
re
80 P
%
Figure 31-3 Average change in glycolated hemoglobin
100
(HgBA1C) levels at 1 and 3 years postoperatively in a pro-
p <0.001
spective randomized study o duodenal switch versus gastric
Figure 31-2 Average weight loss (percent BMI lost) at 4 years bypass. Despite starting at a higher HgBA1C level at baseline,
or duodenal switch (BPD/DS) versus gastric bypass (RYGB) patients undergoing duodenal switch demonstrated lower
patients in a prospective randomized study. Figure repro- levels at 1 and 3 years. Figure reproduced with permission.
duced with permission (Hedberg J et al. 2012). (Hedberg J et al. 2012).

http://surgerybook.net/
11 2 G EN ERAL S U RG ERY EXAM I N ATI O N AN D BO ARD REVIEW
In addition, there is of en a marked improvement
in diabetes immediately af er surgery and this has
been attributed to both the marked change in dietary
intake as well as the bypass o digested ood away
rom the duodenopancreatic complex. One caveat
to the high rates o improvement o obesity-related
comorbidities is that gastroesophageal re ux disease
may not improve, or may even worsen, af er convert-
ing the stomach to a sleeve gastrectomy con gura-
tion. T e percent o excess weight loss seen with the
duodenal switch is typically in the 60% to 80% range
at one year, and has been shown to be superior to
gastric bypass or sleeve gastrectomy alone in multi-
ple series. Resolution rates o 80% to 100% or other
weight related comorbidities including hyperten-
sion, sleep apnea, hyperlipidemia, and hypertriglyc-
eridemia have been demonstrated, and the duodenal
switch has been shown to result in superior reduc-
tion in cardiovascular risk pro les.
4. B. An internal hernia can occur ollowing any sur-
gery that involves division o the small intestine and
then per ormance o an anastomosis, and is one
o the most eared late complications o the duode-
nal switch or gastric bypass. Any acute small bowel
obstruction or chronic abdominal pain syndrome in
these patients should prompt immediate evaluation
or an internal hernia. T e duodenal switch primar-
ily a ects absorption o ats and proteins, and the
at malabsorption may result in signi cant diarrhea
and steatorrhea postoperatively. T e duodenal switch
carries the highest risk o protein/calorie malnutri-
tion due to the high degree o malabsorption, with
approximately 5% o patients requiring parenteral
supplementation or surgical revision.
Surgical revision or this problem usually
involves lengthening o the common channel to
reduce the degree o malabsorption. T e high
degree o at malabsorption a ects the absorption o
the at soluble vitamins (A, D, E, and K), and these
should either be routinely supplemented or closely
monitored and selectively supplemented. Dump-
ing syndrome is thought to be due to rapid passage
o high-carbohydrate and high-osmolar nutrients
directly into the jejunum and is commonly seen
af er gastric bypass surgery. T is can cause immedi-
ate symptoms (early dumping) o abdominal pain,
bloating, diarrhea, ushing, nausea, and emesis and
then delayed symptoms (late dumping) o sweat-
ing, weakness, and dizziness due to hypoglycemia.
http://surgerybook.net/
Dumping syndrome is very uncommon af er the
duodenal switch as the pylorus is preserved and gas-
tric emptying should be more controlled compared
to the gastric bypass.
5. D. Bariatric surgical patients are at risk or a number
o potential perioperative complications in the early
postoperative period. T ese include surgical site
in ections, venous thrombosis, pulmonary embo-
lus, anastomotic or staple line leaks, bleeding, iat-
rogenic bowel injury, and early postoperative bowel
obstruction. T is patients presentation is extremely
concerning due to her abnormal hemodynamics,
abdominal pain, and ever. T e primary concerns in a
patient presenting like this af er a duodenal switch
are or an anastomotic leak, staple line leak ( rom
the sleeve gastrectomy or the duodenal stump), or an
iatrogenic bowel injury. Initial management should
ocus on resuscitation o the patient, identi cation o
the source o the problem (i possible), and prepa-
ration or likely operative intervention. A normal
swallow or upper GI study does not de nitively
rule out an anastomotic leak, and does not evaluate
the duodenal stump or the distal anastomosis.
Although a pulmonary embolus is possible, this
patients constellation o symptoms are much more
consistent with an acute abdominal pathology and
intervention should not be delayed to obtain a C
scan or a less likely diagnosis. T is patient most
likely has a leak rom a staple line or anastomosis
resulting in peritonitis and sepsis. Immediate sur-
gical exploration, either open or laparoscopically,
is indicated to identi y and correct the source o
the problem. I the patient presented with mini-
mal symptoms and normal hemodynamics then a
thorough imaging evaluation would be indicated
to identi y or rule out a leak, and to direct possible
nonoperative management with placement o an
intraluminal stent. Although an internal hernia with
incarcerated and compromised bowel is possible,
these are typically seen much later in the postopera-
tive period (months to years) af er signi cant weight
loss has occurred.
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Endosc. 2005;19:349.
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tional comparison o biliopancreatic diversion with and
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= 50 kg/m 2) compared with gastric bypass. J Gastrointest
Surg. 2010;14:21120.
Ren CJ, Patterson E, Gagner M. Early results o laparoscopic
biliopancreatic diversion with duodenal switch: a case
series o 40 consecutive patients. Obes Surg. 2000;10:514
23; discussion 524.
Sudan R, Jacobs DO. Biliopancreatic diversion with duodenal
switch. Surg Clin North Am. 2011;91:128193, ix.
114 G EN ERAL S U RG ERY EXAM IN ATI O N AN D BO ARD REVIEW
Sovik , Aasheim E , aha O, et al. Weight loss, cardiovas-
cular risk actors, and quality o li e af er gastric bypass
and duodenal switch: a randomized trial. Ann Intern Med.
2011;155:28191.
Strain GW, Gagner M, Inabnet WB, et al. Comparison o
e ects o gastric bypass and biliopancreatic diversion with
duodenal switch on weight loss and body composition 1-2
years af er surgery. Surg Obes Relat Dis. 2007;3:316.
opart P, Becouarn G, Ritz P. Comparative early outcomes o
three laparoscopic bariatric procedures: sleeve gastrectomy,
http://surgerybook.net/
Roux-en-Y gastric bypass, and biliopancreatic diver-
sion with duodenal switch. Surg Obes Relat Dis. 2012;8:
2504.
Ukleja A, Stone RL. Medical and gastroenterologic manage-
ment o the post-bariatric surgery patient. J Clin Gastroen-
terol. 2004;38:31221.
Yimcharoen P, Heneghan HM, ariq N, et al. Endoscopic stent
management o leaks and anastomotic strictures af er ore-
gut surgery. Surg Obes Relat Dis. 2011;7:62836.
 32
Bariatric Surgery
Nutrition Complications
Marcos Molina
A 35-year-old emale with past medical history o
hypertension, ype II diabetes mellitus, and morbid
obesity recently underwent a gastric bypass surgery
8 months ago without complication. On her last visit
o ce visit 2 months ago, no complications were noted
and weight was ound to be appropriate. She is currently
mourning the loss o her grandmother who passed
away 2 weeks ago. oday, her daughter noticed that her
gait was very unsteady and she seemed to be con used.
She also mentioned that she had very poor appetite and
was very unclear i she has been taking her medications.
T ere is no history o alcohol intake. She was taken to
the emergency department or urther evaluation.
1. What is the vitamin de ciency most likely
associated with the above presentation?
A. Vitamin D
B. Folate
C. Vitamin A
D. T iamine
E. Cobalamine
2. What is the next step in management?
A. C scan o the brain
B. Hydration and immediate administration o
100 mg o IV vitamin B1
C. Hydration, T iamine, ollowed by glucose
D. Hydration glucose ollow immediately by
thiamine
E. Oral T iamine
3. What is the most common hematologic nding
af er Roux-en-Y gastric bypass (RYGB) gastric
bypass?
http://surgerybook.net/
A. Iron de ciency anemia
B. Megaloblastic anemia
C. Spherocytosis
D. Anemia o chronic disease
ANSWERS
1. D. Vitamin de ciency is a very common complica-
tion a er bariatric surgery due to the bypass itsel
and the partial gastrectomy, which reduces the
absorptive sur ace area o the stomach. T ere ore, all
patients post-surgery are discharged with multivita-
mins supplements or li e that includes thiamine. T is
case describes the constellation o symptoms con-
sistent with acute Wernicke encephalopathy (WE),
which classically presents with the symptoms o
dementia, ataxic gait, and ocular problems. T ere are
many other micronutrient and vitamin de ciencies
such as calcium, vitamin B12, at-soluble vitamins
(A,D,E,K), olate, and other minerals. Supplementa-
tion o these vitamins is essential post-op.
2. C. WE management requires prompt identi ca-
tion, hydration, and administration o IV thiamine
only based on clinical grounds. T e recommended
regimen is 500 o IV thiamine over 30 minutes three
times a day or 2 consecutive days or intramuscular
or 5 days in combination with other vitamins that
include B12 and olate. It important to administer
glucose a er thiamine de ciency and not be ore
since it is known to worsen the WE symptoms.
3. A. Iron de ciency anemia is commonly seen in
patients who have undergone RYGB secondary
116 G EN ERAL S U RG ERY EXAM I N ATIO N AN D BO ARD REVI EW
to the decrease in pH in the gastric pouch, which
af ects absorption in the duodenum and proximal
jejunum. T e anemia is more evident in the men-
struating emale, there ore, prophylactic iron sup-
plementation is shown to decrease the incidence o
this presentation.
BIBLIOGRAPHY
Brolin RE, Gorman JH, Gorman RC, et al. Prophylactic iron
supplementation a er Roux-en-Y gastric bypass: a pro-
spective, double-blind, randomized study. Arch Surg. 1998;
133:740.
Cook CC, Hallwood PM, T omson AD. B Vitamin de ciency
and neuropsychiatric syndromes in alcohol misuse. Alcohol
Alcoholism. 1998;33:317.
http://surgerybook.net/
Love AL, Billett HH. Obesity, bariatric surgery, and iron de -
ciency: true, true, true and related. Am J Hematol. 2008;
83:403.
Obinwanne KM, Fredrickson KA, Mathiason MA, et al. Inci-
dence, treatment, and outcomes o iron de ciency a er
laparoscopic Roux-en-Y gastric bypass: A10-year analysis.
J Am Coll Surg. 2014;218:246.
Salgado W Jr, Modotti C, Nonino CB, Ceneviva R. Anemia
and iron de ciency be ore and a er bariatric surgery. Surg
Obes Relat Dis. 2014;10:49.
Singh S, Kumar A. Wernicke encephalopathy a er obesity sur-
gery: a systematic review. Neurology. 2007;68:807.
T omson AD, Ryle PR, Shaw GK. Ethanol, thiamine and brain
damage. Alcohol Alcoholism. 1983;18:27.
Wordem, RW, Allen HM. Wernickes encephalopathy a er
gastric bypass that masqueraded as acute psychosis: A case
report. Curr Surg. 2006;63(2):1146.
 33
Revisional Bariatric Surgery
Hussna Wakily
A 45-year-old emale with a history o type 2 diabetes,
hypertension, sleep apnea on CPAP, hyperlipidemia,
and a body mass index (BMI) o 42 presents to clinic
with ailure to lose weight a er having a laparoscopic
adjustable gastric band placed our years ago. She has
been compliant with diet and exercise but has not been
able to lose weight with the band. She is interested in
the Roux-en-Y gastric bypass (RYGB) and would like to
know her options or revisional surgery.
1. Who is the ideal candidate for bariatric surgery?
A. A 50-year-old emale with a BMI o 37 with no
comorbidities.
B. A 34-year-old male with history o GERD and a
BMI o 34.
C. A 19-year-old emale with a history o type 1 dia-
betes, and a BMI o 32.
D. A 48-year-old male with a history o hyperten-
sion, type 2 diabetes, and a BMI o 42.
E. An 89-year-old male with a history o pulmonary
embolus, pulmonary hypertension, and a BMI
o 39.
2. In which scenario would a revisional weight loss
surgery be most indicated?
A. A 45-year-old emale with a history o a lap band
with poor results, a BMI o 44 and poor compli-
ance with diet and exercise.
B. A 38-year-old emale with a history o lap band
with poor results, persistent hypertension, a BMI
o 39, and compliance with nutrition and exercise.
C. An 87-year-old male with a history o RYGB
with poor results, a BMI o 43, active smoker, and
drinks alcohol on weekends.
http://surgerybook.net/
D. A 42-year-old male with a history o RYGB with
a BMI o 32.
E. A 25-year-old emale with a sleeve gastrectomy,
a BMI o 35, and poor compliance with diet and
exercise.
3. An upper gastrointestinal series can be used as part
of the preoperative work up to evaluate for revision
surgery. What will an upper gastrointestinal series
miss that will require a revision?
A. Prolapse or slippage o adjustable gastric band
B. Marginal ulcers
C. Anastomotic leaks
D. Gastro-gastric stulae
4. Patients who have revisional bariatric surgery for
weight recidivism:
A. Have a higher risk o intra-operative and post-
operative complications.
B. Have a predictable amount o weight loss.
C. Do not necessarily need consultation with
behavior health and nutrition care providers.
D. Usually do so due to a technical complication
rom surgery.
ANSWERS
1. D. Ideal candidates or bariatric surgery are those
that have a BMI > 40, or a BMI > 35 and at least
one weight-related co morbidity such as hyperten-
sion, hyperlipidemia, diabetes, sleep apnea, depres-
sion, arthritis, or pseudotumor cerebri. T e National
Institutes o Health (NIH) consensus guidelines
or bariatric surgery are the most commonly used
118 G EN ERAL S U RG ERY EXAM IN ATIO N AN D BO ARD REVI EW
criteria or identi ying patients that will bene t most
rom weight loss surgery. Patient D clearly meets the
NIH guidelines or bariatric surgery and represents
the best candidate among these choices. However, it
should be noted that recent evidence and consensus
opinions support extension o bariatric candidacy in
lower BMI patients, particularly in patients with a
BMI o 30 to 35 and type 2 diabetes.
T e importance o considering weight loss sur-
gery is due to the widespread increase in obesity
and associated co morbidities in the population.
T ere have been many studies showing that surgical
therapy is more e ective than medical intervention
or supervised diet programs at achieving signi cant
and sustained weight loss and resolution o associ-
ated co morbidities.
T ese patients must undergo preoperative screen-
ing prior to surgery that entails psychiatric evalua-
tion, nutritional counseling, and medical clearance.
T ey must be educated very thoroughly on the realis-
tic outcomes and work that is involved in undergoing
weight loss surgery. T e expected weight loss rom
these procedures range rom 40% to 80% o their
excess weight (calculated rom ideal body weight).
2. B. Revisions are necessary or complications o the
initial bariatric procedure or or ailure o weight
loss and/or control o weight-related comorbidities.
Surgery is considered a ailure i the postoperative
BMI remains > 35 less than 50% excess weight loss
achieved, the presence o persistent comorbidities,
or there is signi cant weight regain. Complications
rom the initial procedure that might require surgical
revision can include strictures, ulceration, stulae,
dysphagia, severe re ux, or nutritional de ciencies.
T ese may require surgical revision, conversion to a
di erent bariatric procedure, or in severe cases even
reversal o the bariatric procedure.
Identi ying the source o the complication is criti-
cal to determining candidacy or revision and decid-
ing on the type o revisional procedure. Anatomic
complications can be based on type o surgery. Com-
mon adjustable gastric band complications include
band slippage or gastric prolapse through the band,
band erosion, and pouch or esophageal dilation. In
addition, the adjustable gastric band has the highest
rate o ailure o weight loss or requiring band revi-
sion or removal. Complications o RYGB include
marginal ulcer, internal hernias, bowel obstructions,
gastro-gastric stulas, steatorrhea, inadequate or
http://surgerybook.net/
excessive weight loss, and nutritional de ciencies. It
is crucial to identi y the cause o ailure prior to con-
sidering revision.
Another source o ailure can be behavioral mal-
adaptation or non-compliance. It is critical to have a
standardized approach to the bariatric patient seek-
ing revisional surgery, including complete evalua-
tions o their understanding and compliance with the
required diet and nutritional strategies to maximize
the success o bariatric surgery. I this is the source
than behavioral adjustment may be more bene cial
as opposed to undergoing revision surgery. Patients
who are compliant are probably the best candidates
in which to consider a revision. T ere ore, identi y-
ing the source o the ailure is key to considering who
will bene t rom revision surgery.
3. B. T orough evaluation o the source o the ail-
ure is important to decide which surgery would be
most bene cial, or i revisional surgery is indicated
at all. An upper gastrointestinal (UGI) series is usu-
ally used preoperatively to help clari y the anatomy
o prior surgeries and identi y the presence o com-
plications. It can reliably help identi y band slippage
or prolapse, esophageal dilation, leaks or stulae. A
band that has slipped or caused a prolapse must be
removed because the prolapse can cause an incarcer-
ation o the stomach leading to a surgical emergency.
A gastro-gastric stula may also be seen but not every
stula requires a revision. I the stula is causing
recurrent marginal ulcerations or weight regain then
the patient can then be considered or a revision. It
must always be appreciated that an UGI series may
not identi y small leaks or stulae, and many cent-
ers now per orm an UGI study ollowed immediately
by a C scan. T is approach signi cantly increases
the sensitivity or identi ying smaller leaks, stulae,
or other anatomic complications. Small leaks seen on
UGI can be controlled by drainage, PN, NPO status,
or with the adjunct o a stent or clip place endoscopi-
cally. An UGI study typically lacks the resolution to
identi y subtle mucosal problems such as a marginal
ulcer. Diagnosis o marginal ulceration typically
requires direct luminal visualization with exible
upper endoscopy.
4. A. Revisional surgery is signi cantly more complex
than an initial bariatric procedure or multiple reasons,
including the altered anatomy, presence o signi cant
adhesions or in ammatory changes, and the need or

more complex surgical maneuvers and reconstruc-
tions. T ere have been several studies that have shown
that patients who have undergone revision surgery
have a higher short and long term complication rate.
T ese rates range rom 13% to 50% depending on
the type o revision involved, most commonly being
wound in ections or surgical site in ections. Signi -
cantly longer operative times and greater blood loss
have also been noted. T e mortality rate remains at
less than 1%, similar to initial weight loss surgeries.
T e reported results o additional weight loss a er
revisional surgery are also signi cantly more variable
than a er an initial bariatric procedure.
T ere are multiple options or revision o a bari-
atric procedure, and the choice will depend on the
current anatomy and the reason or the revisional
procedure. T ere is also a signi cant current interest
and developing technology in the eld o endolumi-
nal approaches to both primary and revisional bari-
atric surgery, most commonly to achieve reduction
in the size o the gastric pouch or decrease the size
o a dilated upper anastomosis to produce additional
restriction. Weight loss results are more variable and
less predictable compared to primary bariatric sur-
gery, multiple studies have shown acceptable success
rates with weight loss a er revisional surgeries.
Weight regain a er a primary bariatric proce-
dure can be multi actorial but o en it is due to poor
dietary and exercise habits and not due to a technical
complication rom the surgery. As such, all patients
who being considered or revision need consultation
with behavior health and nutrition services. Follow
up a er surgery should be li e-long to help with
long-term weight management control.
http://surgerybook.net/
C H AP TER 3 3 REVIS I O N AL BARI ATRIC S U RG ERY 119
BIBLIOGRAPHY
Buchs NC, Bucher P, Pugin F, et al. Value o Per orming Rou-
tine Postoperative Liquid Contrast Swallow Studies Fol-
lowing Robot-assisted Roux-en-Y Gastric Bypass. Swiss
Med Wkly. 2012;142:w13556.
Buchwald H. Avidor Y, Braunwald E, et al. Bariatric Surgery:
A Systematic Review and Meta-analysis. JAMA. 2004;
292(14):172437.
Gastrointestinal Surgery or Severe Obesity. NIH Consensus
Development Con erence. Nutrition 1996;12(6):397404.
Grif th PS, Birch DW, Sharma AM, et al. Managing Com-
plications Associated with Laparoscopic Roux-en-Y
Gastric Bypass or Morbid Obesity. Can J Surg. October
2012;55(5):32936.
Inabnet WB 3rd, Belle SH, Bessler M, et al. Comparison o
30-day Outcomes a er Non-LapBand Primary and Revi-
sional Bariatric Surgical Procedures rom the Longitudinal
Assessment o Bariatric Surgery study. Surg Obes Relat Dis.
2010;6(1):2230.
Karmali S, Brar B, Shi X, et al. Weight Recidivism Post-bariatric
Surgery: A Systematic Review. Obes Surg. 2013;23(11):
192233.
Mikami D, Needleman B, Narula V, et al. Natural Ori ce
Surgery: Initial US Experience Utilizing the StomaphyX
Device to Reduce Gastric Pouches a er Roux-en-Y Gastric
Bypass. Surg Endosc. 2010;24(1):2238.
Nesset EM, Kendrick ML, Houghton SG, et al. A wo-decade
Spectrum o Revisional Bariatric Surgery at a ertiary
Re erral Center. Surg Obes Relat Dis. 2007;3(1):2530.
Sjstrm L. Li estyle, Diabetes, and Cardiovascular Risk Fac-
tors 10 Years a er Bariatric Surgery. N Engl J Med. 2004;
351(26):268393.
ran , Pauli E, Lyn-Sue JR, et al. Revisional Weight
Loss Surgery a er Failed Laparoscopic Gastric Banding:
An Institutional Experience. Surg Endosc. 2013;27(11):
408793.
Unick JL, Beavers D, Bond DS, et al. T e long-term e ective-
ness o a li estyle intervention in severely obese individu-
als. Am J Med. 2013;126(3):23642.
 34
Adjustable Gastric Band
Complications
Ashley D. Willoughby

A 37-year-old emale presents to the general surgery
clinic or pre-operative evaluation to undergo a laparo-
scopic adjustable gastric band placement. Her current
weight is 220 lbs (99.8 kg) with a BMI o 35.5 kg/m 2.
She was diagnosed with type 2 diabetes last year and
her primary care physician is currently evaluating her
or obstructive sleep apnea (OSA). T e patient under-
goes her surgery without intraoperative complications.
Post-operatively she has a ew episodes o emesis; how-
ever, she eventually is able to tolerate clear liquids and is
discharged. Six months a er the operation, the patient
presents to the emergency room with intractable nausea
and vomiting, intolerance to ood intake. T e patient is
admitted or urther evaluation and kept NPO with IV
uids. A swallow study was per ormed, results o which
are shown.
1. With regards to outcomes from laparoscopic
adjustable gastric banding (LAGB) placement,
which of the following is true?
A. Excess weight loss at 2 years is about 60% with a
narrow range.
B. Excess weight loss is about 50% with a wide
range.
C. Excess body weight loss is about 45% at 5 years.
D. Inadequate weight loss at 2 years occurs 15% o
the time.
E. Hypertension and hyperlipidemia resolution
is equivalent to the Roux-en-Y gastric bypass
(RYGB).

2. Which of the following is the most common

complication of LAGB placement?
A. Gastric prolapse
B. ubing/access port problems
C. Esophageal dilation
D. IVC inclusion in the band
E. Gastric erosion

3. T e radiology study shown demonstrates:

A. Gastric prolapse
B. Gastric dilation
C. Esophageal ailure

http://surgerybook.net/
 C H AP TER 3 4 Ad j u s TAb l E G As TRi C b An d Co m P l i C ATi o n s
D. IVC inclusion in the band
E. Gastric erosion
4. Which of the following intraoperative or post-
operative strategies described below could have the
greatest impact on preventing this complication?
A. Small portion sizes
B. A rebuckling procedure
C. Pars accida technique
D. Remove all uid rom the band
E. Gastropexy
5. What is the ideal treatment for this complication?
A. Unbuckling, reduction, and rebuckling pro-
cedure
B. Removal with plans to per orm an alternative
weight loss procedure
C. Removal o all uid in band port
D. Band de ation and begin proton pump inhibitor
E. Per orm an esophagogastroduodenoscopy
(EGD) and then remove band i indicated
ANSWERS
1. B. T e Centers or Disease Control and Preven-
tion (CDC) developed the BMI chart comparing an
individuals height and weight to determine i they
all within a healthy range. T e excess weight can
be calculated by calculating the individuals current
BMI and then determining what their weight should
be at that height and subtracting it rom the ormer.
Expected excess weight loss a er undergoing a gas-
tric band operation at 2 years and 5 is 52% and 56%
respectively with standard deviation that ranges
rom 2% to 15%.
2. A. In a review o 2283 patients, a total o 238 (8.5%)
patients experienced a complication a er placement
o a LAGB. T e most requent was proximal pouch
dilation and gastric prolapse (4.2%). T e incidence
o gastric prolapse has decreased since changing
rom the perigastric technique to the pars accida
technique and adding a gastrogastric suture or gas-
troplexy technique. ubing/access port problems
were next at 1.2% as well as explantation. Erosion
into the gastric lumen was the least requent in this
study at 0.5%. Inclusion o the IVC into the band can
result in an intraabdominal or intrathoracic emer-
gency and is a complication that is rare, but reported
and described.
http://surgerybook.net/
121
3. A. Band prolapse occurs when part o the stom-
ach herniates under the band. Gastric prolapse
symptoms include dysphagia, worsening Gastroe-
sophageal Re lux Disease (GERD), nausea/emesis,
and ood intolerance. Patients are at an increase
in risk or gastric prolapse i they have emesis
immediately post-op, which can dislodge sutures
that were placed using the gastroplexy technique
to avoid this complication. A contrast or upper
GI study is used to make the diagnosis. he study
will likely show contrast pooling in the prolapsed
stomach with the band in a horizontal position or
an anterior prolapse (as is the case in the above
scenario) or in a vertical position or a posterior
prolapse. I the gastric wall remains prolapsed it
can become strangulated and may result in gastric
incarceration.
4. E. Restricting the patient to small portion sizes
will prevent gastric dilation, which can lead to
gastric prolapse, but this is not the most e ective
method in preventing this complication. Educat-
ing patients on the importance o portion size does
play a large role in their post-op weight loss success.
An unbuckling, reduction, and rebuckling proce-
dure is per ormed by some surgeons to f x a gastric
prolapse; however, recurrence is common with this
procedure. Removing uid rom the port to a zero
f ll volume is the initial treatment or gastric pro-
lapse and will not necessarily prevent gastric pro-
lapse nor would it assist in weight loss with zero
f ll. Per orming a pars accida technique has been
shown to decrease the incidence o gastric prolapse
when compared to the older perigastric technique;
however placing gastrogastric sutures or per orm-
ing a gastropexy is currently considered the most
e ective technique.
5. B. T e unbuckling, reduction, and rebuckling pro-
cedure is used by some surgeons as a technique to
repair gastric prolapse; however, recurrence rate has
been ound to be quite high. Removal o all uid
in the band port would be considered the non-
operative management or gastric prolapse. T e
patient may be able to consume ood easier when
uid is removed completely rom the band. Remov-
ing all uid in the band port would be the treatment
o choice or gastric pouch dilation, or which the
band would be in normal position on the barium
swallow i this was the diagnosis. Band de ation and
122 G En ERAl s u RG ERY EXAm i n ATi o n An d b o ARd REVi EW
beginning a proton pump inhibitor would be the
recommended treatment or a patient experienc-
ing an exacerbation o GERD symptoms a er band
placement and may ultimately need a laparoscopic
roux-en-y gastric bypass.
An EGD would be indicated to rule out the pres-
ence o a gastric erosion; and i one is seen then
removal o the band and repair o the erosion is indi-
cated. Gastric prolapse can result in a surgical emer-
gency i strangulation or incarceration occurs. I the
patient is hemodynamically stable, then an elective
procedure can be per ormed. T is patient would
benef t rom band removal initially to prevent the
incarceration and plan or a uture weight loss sur-
gery i desired by the patient.
http://surgerybook.net/
BIBLIOGRAPHY
Coburn, Chris; Chapman, Mary Ann; Ali, Arlene; Amrhein,
John. Five-year weight loss experience o outpatients
receiving laparoscopic adjustable gastric band surgery.
Obesity Surgery. 2013;23:90310.
OBrien PE, and Dixon JB. Lap-Band: Outcomes and results.
Journal of Laparoscopic and Advanced Surgical Techniques.
2003;13(4):26570.
Schirmer B, Schauer PR. T e Surgical Management o Obe-
sity. In: Brunicardi FC, Andersen DK, Billiar R, Dunn DL,
Hunter JG, Matthews JB, et al. eds. Schwartzs Principles
of Surgery. 9e. 2010. Accessed rom http://accesssurgery.
mhmedical.com/content.aspx?
Snow J, Severson PA. Complications o adjustable gastric band-
ing. Surgical Clinics of North America. 2011;91:124964.
Walker G. Devine ormula or ideal body weight. MDCalc.
March 03 2014. Accessed rom http://www.mdcalc.com/
ideal-body-weight/
 35
Gallbladder Mass
Douglas Farmer
A 66-year-old Japanese emale is re erred by her
primary physician or long-standing biliary colic symp-
toms. She describes 10 to15 years o intermittent right
upper quadrant (RUQ) pain with nausea that typically
resolves a er 1 to 2 hours. She went to the emergency
room once 6 years ago and had an ultrasound that
showed gallstones. Her medical history is signi cant
or hypertension and osteoporosis. Her vitals and exam
are unremarkable. A repeat RUQ ultrasound ordered
by her primary care physician now shows a large 3 cm
gallstone, as well as a xed mass in the undus, 2 cm
in diameter, that appears to originate rom the gallblad-
der wall. T e immediate surrounding gallbladder wall is
thickened to 8 to 11 mm. A CBC, basic chemistry, and
liver unction tests are all within normal limits.
1. Which o the ollowing is a risk actor or
gallbladder carcinoma?
A. Hemolytic anemia
B. Biliary dyskinesia
C. Clonorchis sinensis in ection
D. Anomalous union o the pancreaticobiliary ductal
system or pancreaticobiliary maljunction (PBM)
E. Auto-immune diseases
2. Which o the ollowing radiographic ndings is
associated with the highest incidence o gallbladder
carcinoma?
A. Pancreaticobiliary maljunction (PBM) without
biliary dilatation identi ed on magnetic reso-
nance cholangiopancreatography (MRCP).
B. Strongly enhancing thick inner layer and a
weakly enhancing or nonenhancing outer layer
http://surgerybook.net/
o the gallbladder wall on the portal phase o a
multi-detector C scan (MDC ).
C. Gallbladder polyp 1020 mm on ultrasound.
D. Gallbladder wall calci cations; porcelain gall-
bladder.
E. Asymptomatic gallstone greater than 3 cm in size.
3. Review o all imaging studies shows a gallbladder
tumor invades into the muscularis propria. T ere
is no lymphadenopathy or distant metastateses
seen. What is the most appropriate next step in
management?
A. Re erral or de nitive treatment with chemo-
therapy and radiation.
B. Re erral or neoadjuvant chemotherapy and
radiation.
C. Schedule or cholecystectomy.
D. Schedule or cholecystectomy with removal o
regional lymph nodes and en-bloc hepatic resection.
4. T e same patient with the same history o present
illness and past medical history instead presents
to the emergency room with RUQ pain. T e
ultrasound in this case is read as 2 large gallstones
with di use gallbladder wall thickening up to
11 mm, pericholecystic f uid, and a normal
common bile duct. Labs show white blood cell
count o 13 and normal liver unction. You take the
patient or laparoscopic cholecystectomy.
T ere was no concern or malignancy during the
procedure. T e gallbladder was removed without
spillage and with a retrieval bag. You see her 2 weeks
later in clinic, and review o the pathology report
12 4 G EN ERAL S U RG ERY EXAM I N ATI O N AN D BO ARD REVIEW
shows 2 adenocarcinoma. All surgical margins,
including cystic duct margin, are reported as clear.
What is the most appropriate course o action?
A. No additional surgery, surveillance with imaging
every 6 months.
B. Staging with imaging ollowed by radical cho-
lecystectomy to include: liver resection with at
least 3 cm o margin around gallbladder bed and
regional lymphadenectomy.
C. Staging with imaging ollowed by radical cho-
lecystectomy and in addition, excision o the
previous laparoscopic port sites.
D. Staging with imaging ollowed by radical cho-
lecystectomy and in addition, excision o the
common bile duct.
E. Staging with imaging ollowed by radical chole-
cystectomy and in addition, excision o both the
common bile duct and the laparoscopic port sites.
5. Which o the ollowing is true regarding the
surgical management or 2 or 3 gallbladder
cancers?
2. B. A recent retrospective study o
A. Formal segmentectomy (4b + 5) improves over-
all survival over wedge resection.
B. Formal segmentectomy reduces local recurrence
rates compared to wedge resection, but overall
survival is the same.
C. Formal segementctomy improves disease ree
survival, but not overall survival.
D. A clear survival bene t or ormal segmentectomy
over wedge resection has not been demonstrated.
ANSWERS
1. D. A history o gallstones is common, and 65% to
90% o those with biliary carcinoma, have a history
o gallstones. T e relation o gallstones to gallbladder
cancer (GBC) is thought to be mediated by chronic
in ammation. T ere is a relatively well-de ned
sequence o at-epithelial premalignant changes
leading to GBC. Chronic in ammation leads to
intermediate low-grade dysplastic changes. Dysplas-
tic progression over time leads to carcinoma-in-situ
and nally invasive carcinoma. Anomalous union o
the pancreaticobiliary ductal system, where the pan-
creatic duct and common bile duct merge outside
the wall o the duodenum and orm a long common
channel, is also associated with an increased risk o
GBC. T is pancreaticobiliary maljunction (PBM)
leads to chronic re ux o pancreatic enzymes.
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T e progression to GBC is likely mediated through
an epithelial hyperplasia with resultant papillary or
villous epithelial changes progressing to GBC. Fur-
ther evidence that this is a distinct pathway rom
chronic in ammation is that the gene alterations o
cancers arising in the setting o cholelithiasis di er
rom anomalies o the duct system associated can-
cers. Adenomas do occur in the gallbladder and can
progress to cancer. However, this likely occurs much
less commonly than the other two pathways, given
a lack o cancer-related molecular changes in most
o these lesions. In ammatory bowel disease is also
associated with increased risk or gallbladder carci-
noma. Clonorchis in ection is associated with risk
or cholangiocarcinoma, but it has not been linked
to carcinoma o the gallbladder. Chronic Salmonella
typhi or paratyphi in ection is, however, associated
with increased risk or gallbladder cancer. Hemolytic
anemia may be a cause o bilirubin type gallstones
but is not a risk actor or gallbladder cancer, neither
is biliary dyskinesia or auto-immune diseases.
ndings on
MDC associated with gallbladder cancer ound
two patterns most associated with nding malig-
nancy at the time o surgery. A strongly enhancing
thick inner layer and a weakly enhancing or non-
enhancing outer layer o the gallbladder wall on
multi-detector C scan was shown to have a 52% to
55% incidence or gallbladder cancer. A single thick
layer with heterogenous enhancement on MDC
had an incidence o 35% to 38% or gallbladder can-
cer. Pancreaticobiliary mal ormation (PBM) without
bile duct dilatation have an incidence o biliary tract
cancer o 37.9%, o which 93.2% o these were gall-
bladder cancer. Based on this data, prophylactic chol-
ecystectomy is recommended or these patients. T e
incidence rates o malignancy in gallbladder polyps
varies widely in published reports but ranges rom
9.6% to 40% or polyps 10 to 20 mm. T e wide vari-
ance is related to various imaging modalities used
and populations studied. Polyps 10 mm, sessile
polyps and rapidly growing polyps are all recom-
mendations or gallbladder removal.
T e nding o gallbladder calci cations or a
porcelain gallbladder was ound to associated with
a malignancy in 6% o cases in a recent systematic
literature review. T is is a ar lower number than
the historically quoted gure o approximately 25%.
Attempts in the review were made to limit inherent

biases in a review o retrospective studies that avor
overestimation but this value likely still overestimates
the true incidence. Given the incidence, the decision
to per orm a prophylactic cholecystectomy should
not be absolute and should be weighed against the
risks o surgery or the individual patient. T e pres-
ence o gallstones is associated with an increased
risk o gallbladder cancer. T e size and volume o
stone burden have been identi ed as potential risk
actors or developing gallbladder cancer. However,
there is no direct evidence o a causal relationship
between gallstones and gallbladder cancer. T e risk
or gallbladder cancer development with a 3 cm or
greater stone has been estimated to be a 2% risk over
a 20 year period.
3. D. T e patient has a 1b lesion or early gallbladder
cancer. Surgical resection is the only curative therapy
or gallbladder cancer. T e general consensus is or
radical cholecystectomy or 1b or greater lesions.
1b tumors have been shown to have lymph node
metastasis in 24% o cases. Lower recurrence rates
and improved survival have been observed with
radical resection including lymph nodes when com-
pared to simple cholecystectomy. A review o the
SEER database showed that the evaluation o even
a single lymph node improved overall survival and
that radical resection without lymph node assess-
ment was no better than cholecystectomy alone or
early stage gallbladder cancer. Neoadjuvant therapy
has been evaluated in the setting o borderline and
unresectable extra-heaptic biliary malignancies with
good results in survival and obtaining negative mar-
gins but none o these addressed gallbladder cancer
speci cally and were con ned to advanced disease.
Adjuvant chemoradiation does have a role in select
gallbladder cancer patients, especially with positive
nodes or margins to improve local control.
4. B. Prognosis o gallbladder carcinoma is determined
by the depth o tumor in ltration and the ability to
obtain a tumor- ree resection margin (R0). For 2 or
greater the de nitive resection should include a min-
imal hepatic resection centered on the gallbladder
bed and a regional lymphadenectomy. T e majority
o experts also extend this recommendation to 1b
tumors but some controversy persists. T ere is uni-
orm agreement that cholecystectomy alone is suf -
cient or is and 1a tumors. T ere is also general
agreement regarding several other technical points,
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C H AP TER 3 5 G ALLBLAD D ER MAS S 125
such as resection o the common bile duct, and the
need or port site excision. Excision o the common
bile duct is only necessary or a positive cystic duct
margin or direct invasion o the hepatoduodenal
ligament.
Regarding routine common bile duct excision
with radical cholecystectomy unless there is direct
invasion o the hepatoduodenal ligament and/or o
the cystic duct, bile duct resection does not result in
decreased recurrence or better overall survival and
does not increase the number o nodes in the speci-
men. Peritoneal involvement with gallbladder cancer
is common and there is theoretical adverse impact
on this with pneumoperitoneum. However, the risk
o port site recurrence is based on per oration o
the gallbladder or extraction without a retrieval bag
rather than the pneumoperitoneum. Port-site exci-
sion does not improve overall or disease- ree sur-
vival in large retrospective series. Port site excision
does not need be routinely per ormed during sec-
ondary procedures or gallbladder cancer discovered
a er laparoscopic cholecystectomy.
5. D. Although some studies have reported anatomi-
cal resection improves survival and R0 resection rate
when compared to wedge resection, other reports
have not demonstrated a bene t. T e majority o
these studies dealt with liver resection or liver metas-
tases. T ere are a ew studies looking at gallbladder
cancer speci cally. Pawlik et al. ound that patients
who underwent a major hepatic resection (e.g., or-
mal segmentectomy o 4b + 5 or hemi-hepatectomy)
had a similar risk o disease-speci c death compared
with patients who underwent a hepatic wedge resec-
tion. Horiguchi et al. ound the overall survival rate
and disease- ree survival rate at 5 years did not
di er signi cantly between wedge resection and
4a + 5 resection group or 2 tumors. T e available
evidence in gallbladder cancer does not show a clear
bene t to anatomic resection. As such, the surgeons
goal should be to resect all disease with negative his-
tologic margins and chose the appropriate operation
to achieve this with the ewest complications.
BIBLIOGRAPHY
Araida , Higuchi R, Hamano M, et al. Should the extrahepatic
bile duct be resected or preserved in R0 radical surgery
or advanced gallbladder carcinoma? Results of a Japanese
Society of Biliary Surgery Survey: A multicenter study. Surg
Today. 2009;39:7709.
126 G EN ERAL S U RG ERY EXAM I N ATI O N AN D BO ARD REVIEW
Azuma , Yoshikawa , Araida , akasaki K. Di erential
diagnosis o polypoid lesions o the gallbladder by endo-
scopic ultrasonography. Am J Surg. 2001;181(1):65.
Cavallaro A, Piccolo G, Panebianco V, et al. Incidental gall-
bladder cancer during laparoscopic cholecystectomy:
Managing an unexpected nding. World J Gastroenterol.
August 14, 2012;18(30):401927.
Diehl AK. Gallstone size and the risk o gallbladder cancer.
JAMA. 1983;250:23236.
Fetzner UK, Holscher AH, and Stippel DL. Regional lymph-
adenectomy strongly recommended in 1b gallbladder
cancer. World J Gastroent. 2011;17(38):43478.
Fuks D, Regimbeau JM, Pessaux P, et al. Is port-site resection
necessary in the surgical management o gallbladder
cancer? J Visc Surg. 2013;150:27784.
Goetze O, Paolucci V. Immediate re-resection o 1 incidental
gallbladder carcinomas: a survival analysis o the German
Registry. Surg Endosc. 2008;22:24625.
Horiguchi A, Miyakawa S, Ishihara S, et al. Gallbladder bed
resection or hepatectomy o segments 4 a and 5 or p 2
gallbladder carcinoma: Analysis o Japanese registration
cases by the study group or biliary surgery o the Japanese
Society o Hepato-Biliary-Pancreatic Surgery. J Hepatobili-
ary Pancreat Sci. 2013;20(5):51824.
Jensen EH, Abraham A, Habermann EB, et al. A critical analysis
o the surgical management o early-stage gallbladder can-
cer in the United States. J Gastrointest Surg. 2009;13:7227.
Jensen EH, Abraham A, Jarosek S, et al. Lymph node evalua-
tion is associated with improved survival a er surgery or
early stage gallbladder cancer. Surgery. 2009;146:70613.
Kim SJ, Lee JM, Lee JY, et al. Analysis o enhancement pattern
o at gallbladder wall thickening on MDC to di erentiate
gallbladder cancer rom cholecystitis. AJR. 2008;191:76571.
Kwon W, Jang J-Y, Lee SE, et al. Clinicopathologic eatures
o polypoid lesions o the gallbladder and risk actors o
gallbladder cancer. J Korean Med Sci. 2009;24:4817.
http://surgerybook.net/
Lee J, Yun M, Kim KS, et al. Risk strati cation o gallbladder
polyps (12 cm) or surgical intervention with 18 F-FDG
PE /C . J Nucl Med. 2012;53:3538.
Maker AV, Butte JM, Oxenberg J, et al. Is port site resection
necessary in the surgical management o gallbladder can-
cer? Ann Surg Oncol. 2012;19:40917.
Marsh R DE W, Alonzo M, Bajaj S, et al. Comprehensive
review o the diagnosis and treatment o biliary tract can-
cer 2012. PAR II: Multidisciplinary management. J. Surg.
Oncol. 2012;106:33945.
Maringhini A, Moreau JA, Melton LJ, et al. Gallstones, gall-
bladder cancer, and other gastrointestinal malignancies.
An epidemiologic study in Rochester, Minnesota. Ann
Intern Med. 1987;107(1):3035.
Miyazaki M, akada , Miyakawa S, et al. Risk actors or
biliary tract and ampullary carcinomas and prophylactic
surgery or these actors. J Hepatobiliary Pancreat Surg.
2008;15:1524.
Numata K, Oka H, Morimoto M, et al. Di erential diagnosis
o gallbladder diseases with contrast-enhanced harmonic
gray scale ultrasonography. J Ultrasound Med. 2007;26:
76374.
Pawlik M, Gleisner AL, Vigano L, et al. Incidence o nd-
ing residual disease or incidental gallbladder carcinoma:
implications or re-resection. J Gastrointest Surg. 2007;11:
147886.
Schnelldor er . Porcelain gallbladder: A benign process or con-
cern or malignancy? J Gastrointest Surg. 2013;17:11618.
Sugiyama M, Atomi Y, Yamato . Endoscopic ultrasonography
or di erential diagnosis o polypoid gall bladder lesions:
Analysis in surgical and ollow up series. Gut. 2000;46:
2504.
Vijayakumar A, Vijayakumar A, Patil V, et al. Early diagnosis
o gallbladder carcinoma: An algorithm approach. ISRN
Radiol. 2013; Article ID 239424:16.
 36
Biliary Colic
Alexander Malloy
A 67-year-old emale presents with sharp, burning right
upper quadrant abdominal pain that radiates to her
back. T e pain awakens her rom sleep. She has experi-
enced nausea and three episodes o emesis. She reports
burning substernal and epigastric pain. She denies any
evers or chills. She is hemodynamically normal and
a ebrile. Laboratory workup reveals a normal hepatic
unction panel, a normal basic chemistry, and a normal
white blood cell count. Her abdominal exam is remark-
able or mild tenderness in the right upper quadrant
without peritoneal signs. A er three hours, her pain
resolves.
1. What is the next best test in this patients scenario?
A. Plain lms o the abdomen
B. Cholecystokinin stimulated cholescintigraphy
C. Right upper quadrant ultrasound
D. Computed tomography (C ) o the abdomen
E. Esophagogastroduodenoscopy (EGD)
2. T e appropriate imaging is ordered and shows no
abnormality. Which is the next most appropriate
step in management?
A. Cholecystectomy
B. Esophagogastroduodenoscopy
C. Right upper quadrant ultrasound in two weeks
D. Proton pump inhibitor administration
E. Bile microscopy
3. T e patient returns to the emergency department
one month later with similar symptoms. A
right upper quadrant ultrasound is performed
that shows gallstones without signs of acute
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cholecystitis. Her pain again resolves and she is
referred to your clinic the following week. You
discuss performing a cholecystectomy with the
patient, which she refuses. Which of the following
is true regarding medical therapy of cholelithiasis?
A. Ursodiol therapy typically resolves biliary symp-
toms within one month.
B. Complete resolution o cholelithiasis is success-
ul in less than 40% o patients.
C. I biliary symptoms persist while on ursodiol,
cholecystectomy is indicated.
D. T e mechanism o action o ursodiol includes
reduction in bile synthesis.
E. Extracorporeal shockwave lithotripsy (ESWL)
has a symptomatic recurrence rate o 30%.
4. T e patients ultrasound, in addition to
cholelithiasis, is also notable for a 1.5 cm non-
mobile polypoid lesion in the fundus of the
gallbladder. Which of the following is true?
A. Polyps greater than 5 mm are a risk actor or
gallbladder cancer.
B. Patients with large (> 2.5 cm) gallstones are
more likely to develop gallbladder cancer than
those without.
C. Laparoscopic cholecystectomy should be per-
ormed, a rozen analysis should be done, and i
positive, an oncologic resection should be done
laparoscopically.
D. Multiple pedunculated subcentimeter lesions are
also a risk actor or gallbladder adenocarcinoma.
E. Extended cholecystectomy is not required or gall-
bladder adenocarcinomas with up to 3 lesions.
128 G EN ERAL S U RG ERY EXAM I N ATI O N AN D BO ARD REVI EW
ANSWERS
1. C. T is scenario describes symptomatic cholelithia-
sis, or biliary colic. Plain lms o the abdomen would
not be a high yield study as less than 10% o gall-
stones are radio-opaque, nor would it o er speci c
imaging o the biliary system. Other yields rom a
plain lm would be presence o nephrolithiasis or
ree air (Choice A). A hepatobiliary (HIDA) scan is
the gold standard or the diagnosis o acute chole-
cystitisa clinical scenario in which she does not t
criteria (Choice B). With the cholecystokinin injec-
tion, the nuclear imaging study can be diagnostic or
biliary dyskinesia. C can o en visualize gallstones
but is not the recommended imaging modality o
choice or cholelithiasis as the sensitivity is 55% to
80% (Choice D); cholelithiasis is o en ound inci-
dentally on C scan when the imaging is per ormed
or other reasons.
Esophagogastroduodenoscopy could be help ul
to rule out peptic ulcer disease that can some-
times mimic symptoms o biliary colic, but this test
would not be the ideal next choice in this situa-
tion (Choice E). T e most common initial imaging
modality in biliary disease is the right upper quad-
rant ultrasound. Ultrasound has a sensitivity o 84%
and speci city approaching 99% or the diagnosis o
cholelithiasis (Choice C). Simultaneously, assessment
or signs o acute cholecystitis, choledocholithiasis,
and hepatic pathology can be sought.
2. C. T is patient should have had a right upper
quadrant ultrasound per ormed in the rst ques-
tion above. I this imaging modality shows no
abnormality, but the patient has biliary symptoms,
she should have a repeat right upper quadrant
ultrasound per ormed in two weeks with ocus on
areas that may have missed stones smaller than
3 mm (Choice C).
Esophagogastroduodenoscopy is an appropri-
ate diagnostic modality to rule out peptic ulcer dis-
ease and can be utilized i the repeat ultrasound is
still negative. Bile microscopy has been shown as an
adjunct study to assess or microlithiasis and can be
help ul (Choice E), although is not routinely per-
ormed; bile microscopy also requires endoscopy
or collection. T e sensitivity o bile microscopy
or microlithiasis is 65% to 90%. Cholecystectomy
is not recommended at this time as other causes
o the patients symptoms have not been ruled out.
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Cholecystokinin stimulated cholescintigraphy can
help identi y a unctional gallbladder problem that
may warrant cholecystectomy i positive (Choice A).
Proton pump inhibitor therapy may help with re ux
symptoms but does not speci cally address biliary
symptoms (Choice D).
3. B. Ursodiol may take up to 3 months to show
improvements in biliary symptoms, and can take up to
3 years to completely dissolve gallstones (Choice A).
A meta-analysis o treatment with ursodiol showed
that only 37% o patients had complete resolution
o biliary symptoms; cholecystectomy remains the
pre erred choice in surgical candidates (Choice B).
Many patients who undergo initial medical therapy
with ursodiol do progress to surgical treatment, but
they tend to show initial improvement in symptoms.
I biliary symptoms progress while being treated
with ursodiol, other causes must be ruled out, such
as sphincter o Oddi dys unction or peptic ulcer
disease (Choice C). T e mechanism o action o
ursodiol involves reducing absorption in the duode-
num, resulting in disruption o micelles and reduced
cholesterol absorption, thereby decreasing choles-
terol concentration; ursodiol is not involved with
the synthesis o bile (Choice D). Extracorporeal
shockwave lithotripsy can be utilized as nonsurgical
therapy, but has a recurrence rate o approximately
20%. Indications include patients with single stones,
between the sizes o 5 mm and 2 cm. ESWL is not
commonly o ered as medical therapy due to the ef -
cacy and commonplace practice o cholecystectomy
(Choice E).
4. B. T is patient should undergo open cholecystec-
tomy with a symptomatic, visualized preoperative
intraluminal gallbladder lesion that is 1.5 cm in
size. T e open cholecystectomy is pre erred, because
gallbladder per oration or bile spillage during lapa-
roscopic cholecystectomy can potentially seed the
peritoneal cavity. Polypoid lesion size greater than
1 cm is an independent risk actor or gallbladder
adenocarcinoma, along with stone size greater than
2.5 cm (Choice A, B). Gallbladder cancer has a 3:1
ratio o incidence in women and typically presents
a er age 60. Extended cholecystectomy is not indi-
cated i the lesion is con ned below the muscle layer
o the gallbladder. I the lesion is 2 or greater, resec-
tion usually includes segments IVb and V o the liver
(Choice E). Choice D is descriptive o cholesterol

polyps, which are not a risk actor or gallbladder
adenocarcinoma.
BIBLIOGRAPHY
Barakos JA, Ralls PW, Lapin SA, et al. Cholelithiasis: Evalua-
tion with C . Radiology. 1987;162:415.
Ca asso DE, Smith RR. Symptomatic cholelithiasis and unc-
tional disorders o the biliary tract. Surg Clin North Am.
April 2014;94(2):23356.
Coburn NG, Cleary SP, an JC, Law CH. Surgery or gallblad-
der cancer: A population-based analysis. J Am Coll Surg.
September 2008;207(3):37182. Available rom http://www.
sciencedirect.com/science/article/pii/S1072751508002731.
Corazziari E, Sha er EA, Hogan WJ, et al. Functional disor-
ders o the biliary tract and pancreas. Gut. 1999;45(Suppl 2):
1148.
Darzi A, Geraghty JG, Williams NN, Sheehan SS, anner AN,
Keane FB. T e pros and cons o laparoscopic cholecys-
tectomy and extracorporeal shock wave lithotripsy in the
management o gallstone disease. Ann R Coll Surg Engl.
1994;76(1):42.
Diehl AK, Sugarek NJ, odd KH. Clinical evaluation or gall-
stone disease; use ulness o symptoms and signs in diagno-
sis. Am J Med. 1990;89:29.
Friedman GD. Natural history o asymptomatic and symp-
tomatic gallstones. Am J Surg. 1993;165:399.
Lee SP, Nicholls JF. Nature and composition o biliary sludge.
Gastroenterology. 1986;90:677.
Misra S, Chaturvedi A, Misra NC, Sharma ID. Carcinoma o
the gallbladder. Lancet Oncol. 2003;4(3):167.
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C H AP TER 3 6 BI LI ARY CO LI C 129
Moskovitz M, Min C, Gavaler JS. T e microscopic examina-
tion o bile in patients with biliary pain and negative imag-
ing tests. Am J Gastroenterol. 1986;81:329.
Maton PN, Iser JH, Reuben A, Saxton HM, Murphy GM,
Dowling RH. Outcome o chenodeoxycholic acid (CDCA)
treatment in 125 patients with radiolucent gallstones.
Factors in uencing ef cacy, withdrawal, symptoms and
side e ects and post-dissolution recurrence. Medicine
(Baltimore). 1982;61(2):86.
Okamoto M, Okamoto H, Kitahara F, et al. Ultrasonographic
evidence o association o polyps and stones with gallblad-
der cancer. Am J Gastroenterol. 1999;94(2):446.
Reddy YP, Sheridan WG. Port-site metastasis ollowing lapa-
roscopic cholecystectomy: A review o the literature and a
case report. Eur J Surg Oncol. February 2000;26(1):958.
Ricardo AE, Feig BW, Ellis LM, et al. Gallbladder can-
cer and trocar site recurrences. Am J Surg. December
1997;174(6):61922; disc 6223.
Rubin RA, Kowalski E, Khandelwal M, Malet PF. Ursodiol
or hepatobiliary disorders. Ann Intern Med 1994;121:207.
Sarkut P, Kilicturgay S, Ozer A, Ozturk E, Yilmazlar . Gall-
bladder polyps: Factors a ecting surgical decision. World J
Gastroenterol. July 2013;19(28):452630.
Shea JA, Berlin JA, Escarce JJ, Clarke JR, Kinosian BP, Cabana
MD, et al. Revised estimates o diagnostic test sensitivity
and speci city in suspected biliary tract disease. Arch
Intern Med. 1994;154(22):2573.
omida S, Abei M, Yamaguchi , et al. Long-term ursode-
oxycholic acid therapy is associated with reduced risk o
biliary pain and acute cholecystitis in patients with gall-
bladder stones: a cohort analysis. Hepatology. 1999;30:6.
 37
Biliary ractCholangitis
Harry T. Aubin
A 70-year-old male presents to the emergency depart-
ment with altered mental status. Family reports he was
complaining o right upper quadrant abdominal pain
prior to becoming altered mentally. On arrival, he is
ound to have a temperature o 102.5F, heart rate o
112, and systolic blood pressure o 80 despite 2 liters o
crystalloid in usion. On exam, he is visibly jaundiced
with tenderness in the right upper quadrant. He has
3 out o 4 systemic in ammatory response syndrome
(SIRS) criteria. He is started on pipericillin/tazobac-
tam and admitted to the intensive care unit or invasive
monitoring and vasopressor support.
1. Regarding this patients constellation o symptoms,
what is the most common cause?
A. Gallstones
B. Biliary stricture
C. Malignancy
D. Genetic disorder
2. Regarding the pathophysiology o cholangitis,
which o the ollowing is correct?
A. Increased biliary pressure leads to decrease in
production o IgG in the biliary mucosa lead-
ing to increased translocation o duodenal
bacteria.
B. Intra-portal toxins and bacteria can cross
through the biliary system due to stasis leading
to in ection.
C. Stones do not colonize with bacteria.
D. Biliary stents are not elt to contribute to or cause
cholangitis as they help decompress the biliary
tree.
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3. Regarding the proper diagnostic workup, which
noninvasive test has highest sensitivity and specif city
or detecting the most common cause?
A. Abdominal ultrasound
B. Magnetic resonance cholangiopancreatography
(MRCP)
C. C Scan
D. Hepatobiliary (HIDA) scan
4. Regarding the management o septic cholangitis
caused by choledocholithiasis, which o the
ollowing is correct?
A. Urgent biliary tract decompression via endoscopic
retrograde cholangiopancreatography (ERCP) is
success ul 60% o the time.
B. Percutaneous transhepatic cholangiography
(P C) is easible or stone extraction and stent
placement.
C. ERCP with a sphincterotomy is equivalent to
cholecystectomy or reducing recurrence rates.
D. Should ERCP and P C ail or are not easible,
operative choledochotomy and -tube place-
ment should be avoided because o the risk o
surgery.
E. Broad spectrum antibiotic therapy alone will
generally provide adequate treatment.
ANSWERS
1. A. Cholangitis is caused by obstruction o the bil-
iary tree eventually leading to bile stasis and bacterial
in ection. T e most common cause being gallstones,
which account or around hal o cases. Other causes
 C H AP TER 3 7 Bi l i ARy TRAC T C H o l An g i Ti s
include stenosis/biliary stricture, malignancy and bil-
iary stents. Stents can cause obstruction rom migra-
tion, occlusion, or colonization by bacteria leading to
bacterial overgrowth and translocation into the blood
stream.
2. B. Obstruction o the biliary tree via stricture/
stenosis, stones, malignancy, or stent occlusion leads
to increased biliary tract pressure. T is pressure
promotes stasis o bile and decreases production o
IgA in the bile tract mucosa. T e lack o continuous
bile ow, coupled with decrease mucosal protection
allows or bacterial translocation rom the duode-
num through the biliary tract. T is static bile and
gallstones provide a healthy growth medium or bac-
teria. T e elevated intra-biliary pressure allows or
translocation o these pathogens into the systemic
circulation causing septicemia. Less commonly, bac-
teria and toxins can enter through the portal circula-
tion into the bile due to increase biliary pressure.
T e most common bacteria are gram negative
enteric pathogens: E coli, klebsiella, and enterobac-
ter. T ey carry LPS that promotes cytokine release
and leads to septic shock. Enterococcus is seen in a
smaller set o cases.
3. B. MRCP is the best non-invasive test to con rm the
presence o choledocholithiasis due to its high sensi-
tivity (some studies quoting 100%) and nearly 100%
speci city. I the test is positive then this con rms
diagnosis. It also is help ul in evaluating or stricture
and ampullary masses. Ultrasound is a good screen-
ing tool and can evaluate or common bile duct dila-
tation to perhaps lend clinical suspicion to presence
o biliary obstruction. It is best at identi ying the
presence o cholelithiasis/cholecystitis. However, it
has lower accuracy in identi ying the presence o a
choledocholith, roughly 80%.
A C scan is less use ul than ultrasound in detect-
ing cholecystitis/common bile duct dilatation, but is
help ul at evaluating or ampullary masses as a cause
o a dilated common bile duct.
HIDA scans are not use ul in the setting o chol-
angitis as the biliary tract in ection reduces secretion
o the radio nucleotide labeled marker into the bil-
iary tree. It may show, however, obstruction with lack
o ow into the duodenum.
4. B. In cases o cholangitis without septic shock, a
trial o antibiotic therapy is recommended as this
can resolve symptoms and ensure stability in up to
http://surgerybook.net/
1 31
80% o patients. Routine ERCP can be per ormed
in this setting assuming the patient remains stable.
T is patient displays Reynolds pentad o ever, right
upper quadrant pain, jaundice, altered mental status,
and hypotension, the rst three signs constituting
Charcots triad. T is lends suspicion to suppurative
cholangitis due to the patients state o septic shock.
Antibiotics, though required as initial therapy, are
unlikely to complete resolve this patients septic
physiology. Emergent/urgent biliary tree decompres-
sion is warranted and must be per ormed to prevent
excessive morbidity/mortality.
ERCP with sphincterotomy has shown upwards o
a 95% success rate in stone extraction and decreasing
the rate o recurrence o cholangitis. It is, however,
not superior to cholecystectomy in decreasing rates
o recurrence and thus cholecystectomy is recom-
mended a er the ERCP/sphinceterotomy once the
septic physiology has resolved. Arguments or early
cholecystectomy have been made as waiting 6 to
8 weeks runs the risk o 20% recurrence rate o a
gallstone related event.
Should ERCP ail, P C is warranted as both these
procedures decrease the morbidity/mortality risk o
a common bile duct exploration. P C can be chal-
lenging i there is little intra-hepatic ductal dilatation
and it also does not allow sphincterotomy.
Common bile duct exploration is warranted
should ERCP and P C ail at decompressing the bil-
iary tree. In the setting o a patient who is in septic
shock, choledochotomy with stone extraction and
-tube placement is recommended as this allows
or decompression o the biliary tree and allows or
sepsis to resolve prior to per orming cholecystec-
tomy to limit the morbidity and mortality associated
with both procedures. T e exploration is per ormed
through a choledochotomy on the common bile duct
distal to the insertion o the cystic duct. Stay sutures
are placed on either side o the choledochotomy
and using balloon catheters, uoroscopy with bas-
ket retractors, and ushing, stone extraction is per-
ormed. In general, the choledochotomy should be
roughly the size o the largest stone. It is best done
in dilated ducts as the risk o stenosis is high in
the setting o common bile duct size <6 mm.
A large bore -tube is placed and the choledochot-
omy repaired over the -tube with 4-0 absorbable
sutures. T e tube is externalized and bile allowed to
drain into an external bag. Due to lack o re-absorption
o bile, a patient with this procedure is prone to being
132 g En ERAl s U Rg ERy EXAM i n ATi o n An D Bo ARD REVi EW
de cient in at soluble vitamins (A, D, E, and K). It is
the vitamin K de ciency which is most worrisome as
it can lead to a coagulopathy.
BIBLIOGRAPHY
Hui CK, Lai KC, Yuen MF, Ng M, Lai CL, Lam SK. Acute
cholangitispredictive actors or emergency ERCP. Aliment
Pharmacol T er. October 2001;15(10):16337.
Kimura Y, akada , Kawarada Y, et al. De nitions, pathophys-
iology, and epidemiology o acute cholangitis and chole-
cystitis: okyo Guidelines. J Hepatobiliary Pancreat Surg.
2007;14(1):1526.
Lai EC, Mok FP, an ES, et al. Endoscopic biliary drainage or
severe acute cholangitis. N Engl J Med. 1992;326(24):15826.
Lai EC, am PC, Paterson IA, et al. Emergency surgery or
severe acute cholangitis. T e high-risk patients. Ann Surg.
1990;211(1):559.
http://surgerybook.net/
Leung JW, Sung JY, Costerton JW. Bacteriological and electron
microscopy examination o brown pigment stones. J Clin
Microbiol. 1989; 27(5):91521.
Schiphorst AH, Besselink MG, Boerma D, et al. iming o
cholecystectomy a er endoscopic sphincterotomy or
common bile duct stones. Surg Endosc. September 2008;
22(9):204650.
Shimizu S, Yokohata K, Mizumoto K, Yamaguchi K,
Chijiiwa K, anaka M. Laparoscopic choledochotomy
or bile duct stones. J Hepatobiliary Pancreat Surg.
2002;9(2):2015.
Singh A, Mann HS, T ukral CL, Singh NR. Diagnostic Accu-
racy o MRCP as Compared to Ultrasound/C in Patients
with Obstructive Jaundice. J Clin Diagn Res. March 2014;
8(3):1037.
Sung JY, Costerton JW, Shaf er EA. De ense system in the
biliary tract against bacterial in ection. Dig Dis Sci. 1992;
37(5):68996.
 38
Cholecystitis in Pregnancy
Alan P. Gehrich
A 32-year-old gravida 2 para 1 emale at 28 weeks gesta-
tion presents with acute onset o right upper quadrant
and right upper ank pain with associated nausea and
vomiting over the preceding 24 hours. She has no signi -
icant medical or surgical history. She has had 1 uncom-
plicated vaginal delivery. At the time o her evaluation,
her temperature is 99.8F, heart rate is 110, and respira-
tory rate is 24. Her exam documents a positive Mur-
phys sign and guarding in the right upper quadrant.
Laboratory studies show the ollowing: WBC 20,000,
H/H- 9/29, Platelets 130,000, AL -60, and AS 90. Her
bilirubin, lipase, and amylase levels are normal. Her uri-
nalysis is within normal limits.
1. Which of the following diagnoses is the least
common disease in pregnancy presenting with
right upper quadrant pain?
A. Acute atty liver o pregnancy
B. Cholecystitis
C. Cholelithiasis
D. HELLP syndrome
E. Appendicitis
2. Which of the following statements is correct
concerning Acute Fatty Liver of Pregnancy (AFLP)?
A. AFLP presents most commonly in the second
trimester o pregnancy.
B. AFLP commonly presents with serum amino-
trans erase levels similar to those ound in gall-
bladder disease.
C. AFLP can present with hypoglycemia and occa-
sionally renal ailure which can help distinguish
it rom HELLP (hemoconcentration, elevated
http://surgerybook.net/
liver enzymes, low platelet) syndrome and gall
bladder disease.
D. In a preterm pregnancy, it is considered sa e to
continue the pregnancy in a patient who has
been diagnosed with AFLP.
3. Which of the following statements regarding radio-
graphic imaging of biliary disease in pregnancy is
correct?
A. Classic sonographic signs o biliary disease are
altered in pregnancy.
B. T e risk o radiation exposure to the etus
with ERCP (endoscopic retrograde cholangio-
pancreatography) is high throughout pregnancy.
C. T e neuronal development o the etus is most
sensitive to radiation between 20 to 28 weeks
gestation.
D. Exposure to less than 5 rad o ionizing radiation
has not been associated with an increased risk o
etal anomalies or pregnancy loss.
E. MR imaging has a higher sensitivity and speci c-
ity in the diagnosis o cholecystitis than ultraso-
nography.
4. In this patient, acute cholecystitis is diagnosed
by ultrasound. Which of the following is correct
regarding treatment of this patient?
A. T e risk o adverse e ects o laparoscopy is high
even with maximal intra-abdominal pressures
limited to 9 mm Hg.
B. I le untreated, the most common complication
o acute cholecystitis in pregnancy is gangrenous
cholecystitis.
134 G EN ERAL S U RG ERY EXAM I N ATI O N AN D BO ARD REVI EW
C. Available studies have shown signi cant di er-
ences regarding preterm delivery rates, birth
weights or neonatal outcomes when comparing
laparoscopic versus open cholecystectomies.
D. Nonsteroidal anti-in ammatory drugs (NSAID)
treatment or pain expected to last more than
48 to 72 hours is the pharmacologic option o
choice a er 30 weeks gestation to avoid etal
complications.
E. Beta-lactam antibiotics such as ampicillin-
sulbactam or piperacillin-tazobactam are con-
traindicated in pregnant patients.
5. T is patient undergoes an uncomplicated laparo-
scopic cholecystectomy. On postoperative day 2,
she develops increasing pain in her right upper
quadrant (RUQ) with fever and recurrent leukocy-
tosis as well as elevated total bilirubin, transaminase,
lipase and amylase levels. RUQ ultrasound documents
dilated biliary ducts. Which of the following would
be the most appropriate next step?
A. MRCP (magnetic resonance cholangio-pancre-
aticogram)
B. ERCP
C. Continued observation with antibiotic therapy
D. Repeat surgery with bile duct exploration
E. Delivery o the etus
ANSWERS
1. A. T e most common surgical disease in pregnancy
is appendicitis with an incidence o 1 in 1000 to
2000 pregnancies. Gall bladder disease is the second
most common surgical disease in pregnancy with
an incidence o 1 in 1200 to 1 in 10,000. T eoreti-
cally, the incidence o gall bladder disease including
cholelithiasis, cholecystitis, and cholangitis should be
increased in pregnancy. T e elevated level o serum
estrogen seen in pregnancy increases cholesterol
secretion, whereas the elevated level o progesterone
reduces soluble bile acid secretion and slows emp-
tying o gallbladder. Despite the predilection toward
biliary sludge and stone ormation, cholecystitis does
not occur more requently during pregnancy. Appen-
dicitis occurs with equal requency in each trimes-
ter and the incidence is not increased in the gravid
patient.
T e di erential diagnosis or RUQ abdominal
pain is expanded in pregnancy. It includes gastro-
intestinal disorders such as pancreatitis, peptic ulcer
http://surgerybook.net/
disease, hepatitis, and appendicitis, due to a superiorly
displaced cecum, as well as pyelonephritis, nephro-
lithiasis, right lower lobe pneumonia, peptic ulcer
disease, and myocardial in arction. Obstetric speci c
diagnoses must also be included in the di erential to
include preeclampsia, HELLP (Hemolysis, Elevated
Liver enzymes, Low Platelets) syndrome and acute
atty liver o pregnancy (AFLP). HELLP syndrome
is a severe orm o preeclampsia occurring in up to
8 o 1000 pregnancies presenting most commonly
in the third trimester o pregnancy. T is syndrome
generally involves the characteristic hypertension
and proteinuria seen with preeclampsia with evi-
dence o liver dys unction and a consumptive coag-
ulopathy which can rapidly progress to ulminant
DIC. Patients with preeclampsia may present with
right upper quadrant or epigastric pain due to liver
involvement and in the most severe cases subcap-
sular hemorrhage or hepatic rupture. AFLP is a rare
diagnosis, seen in 1:20,000 pregnancies.
T is patient presents with ndings consistent with
an in ammatory intra-abdominal process. Chol-
ecystitis, choledocholithiasis, and cholangitis lead
the di erential diagnosis. T e physical exam ndings
are highly suggestive o gallbladder disease. WBC
counts and alkaline phosphatase levels are routinely
elevated during pregnancy and there ore may not be
as speci c or in ammation during the assessment o
the gravid patient.
2. C. T e AFLP syndrome almost always presents in
the third trimester with serum aminotrans erase
elevations up to 1000 IU/L, which is generally higher
than those ound in gallbladder disease. AFLP can
also present with hypoglycemia and renal ailure,
which is not characteristic o either HELLP or gall-
bladder disease. Findings o AFLP can still signi -
cantly overlap with those o HELLP, making it very
dif cult to distinguish these two syndromes. T e
treatment or both is the emergent delivery o the
etus.
3. D. Due to the acuity o presentation and the myriad
o diagnoses in the di erential, imaging is an essen-
tial component in the diagnostic evaluation. Risks o
radiologic studies to the etus must there ore be con-
sidered. Sonography is the appropriate rst line diag-
nostic modality in pregnancy or both biliary disease
and appendicitis as this modality has a high diagnos-
tic accuracy (90% to 100% or both diagnoses) and
 C H AP TER 3 8 C H O LEC YS TI TI S IN P REG N AN C Y
has no known risk to the etus. Classic ultrasound
(US) ndings to include wall edema, pericholecystic
uid, calculi, and songraphic Murphys sign main-
tain their sensitivity and speci city in pregnancy. I
ultrasound studies are non-diagnostic, MR imaging
without contrast has become the con rmatory test
or appendicitis. For biliary disease, an MRCP can
be used in equivocal cases or in suspected cases o
choledocholithiasis or cholangitis. It is not as sensi-
tive as US or cholecystitis. Intraoperative cholan-
giogram in combination with cholecystectomy is an
option or diagnostic evaluation a er etal organo-
genesis is complete in the second trimester and does
not appear to increase the risk or preterm delivery
or adverse etal outcomes. I MRCP documents stone
disease in the biliary tree, ERCP is considered a via-
ble therapeutic option a er the rst trimester. T e
risks to the etus with cholangiogram and ERCP can
be reduced with shielding.
C scan o the abdomen, which is the pre erred
imaging modality or appendicitis in the non-
pregnant patient, con ers radiation levels o 5 to
10 rads which approach the maximum permissible
radiation dose or etal exposure during pregnancy.
Fetal exposure to ionizing radiation increases risks
o microcephaly, micropthalmia, mental retarda-
tion, growth restriction, and cataracts. T e concern
o ionizing radiation is greatest during organogen-
esis which alls between 320 weeks o gestation.
T e above patient is at 28 weeks and there ore the
risk o serious complications with ionizing radia-
tion is limited. C generally remains behind US and
MR on the imaging algorithm or both appendicitis
and cholecystitis even in the patient with a etus o
advanced gestational age due to the disputed two old
increased risk o carcinogenesis (1:1000) in the etus.
C imaging should, however, not be abandoned as a
diagnostic modality, as the risk o delay in diagno-
sis ar outweighs the risk o radiation. T e consult-
ing radiologist can design C protocols to minimize
the associated risks and counseling can minimize the
associated anxiety o the patient.
4. B. Initial non-surgical management can be considered
in hemodynamically normal pregnant patients experi-
encing cholelithiasis. T is management plan generally
involves bowel rest, intravenous hydration, and NSAID
therapy. A short course (< 48 to 72 h) o indomethacin
treatment can provide e ective analgesia but is gen-
erally avoided in late pregnancy due to the potential
http://surgerybook.net/
135
adverse etal e ects. Use in the third trimester increases
the risk o premature closure o the patent ductus
arteriosis and oligohydramnios. Intravenous antibi-
otics to include ampicillin-sulbactam, piperacillin-
tazobactam, and ticarcillin-clavulanate are not con-
traindicated in pregnant patients who need antibiotics
or acute cholecystitis or choledocolithiasis
Early surgery has been advocated or all types o
biliary disease in pregnancy. I not treated, cholecys-
titis can lead to li e threatening complications, the
most common o which is gangrenous cholecystitis
ollowed by abscess ormation, per oration, stula,
ileus, or emphysematous cholecystitis. For sympto-
matic cholelithiasis with no evidence o cholecysti-
tis, surgery can be delayed. However the literature
reports that surgical management o symptomatic
cholelithiasis in pregnancy is sa e, decreases hospital
days, reduces emergency room visits, and the rate o
preterm deliveries. T e second trimester ( rom 13 to
27 weeks gestation) is considered the best time rame
or cholecystectomy as the uterus is not obstructing
the view o the surgical eld, and the risk o miscar-
riage or preterm birth is lowest. In this patient, with
clear evidence o cholecystitis, surgical intervention
is warranted to reduce risk o serious complications.
I complications such as cholangitis or gallstone pan-
creatitis develop in a pregnant patient, maternal mor-
tality may approach 15% and etal loss up to 60%.
Surgical management o biliary disease has been
revolutionized with the advent o laparoscopy. Lapa-
roscopic technique can be utilized sa ely in preg-
nancy across all trimesters depending on the com ort
level o the surgeon. Although data is limited, lapa-
roscopy does not con er an increased risk o adverse
pregnancy outcomes to include preterm delivery as
compared to laparotomy. Proper positioning in le
lateral tilt is important to reduce venal caval com-
pression and maintain adequate placental blood
ow, and open entry technique is recommended to
prevent injury to the enlarged gravid uterus. Intra-
abdominal pressure with pneumo-peritoneum
should be limited to 10 to 12 mm Hg to reduce the
theoretical concern o etal acidosis associated with
the e ect o CO2. T ere is no indication or intraop-
erative etal monitoring.
Early surgery or appendicitis is also recom-
mended in pregnant patients, as the consequences or
both the mother and etus can be catastrophic. Abbasi
et al., in the largest case series to date involving 7000
patients, documents a markedly increased risk o
136 G EN ERAL S U RG ERY EXAM IN ATI O N AN D BO ARD REVIEW
severe complications with conservative management
to include miscarriage and maternal sepsis. As with
cholecystitis, non-operative management o appendi-
citis is contraindicated in pregnancy.
5. B. Following cholecystectomy, this patient presents
with ndings consistent with choledocholithiasis,
with associated gallstone pancreatitis and possible
cholangitis. T e best option in this case is ERCP
with the option o sphincterotomy to decompress
the biliary tract. T is approach appears sa e in preg-
nant patients with early onset cholangitis with lower
morbidity than conservative management. In this
patient, repeat surgery with intraoperative cholan-
giography or bile duct exploration would be a back-
up option, i the stones cannot be removed via ERCP.
Percutaneous biliary tract decompression would be
another option in a high risk patient. MRCP is an
excellent and sa e diagnostic test in pregnancy and
is a viable option in patients where the diagnosis is
uncertain.
In a case with a high suspicion o cholangitis, this
step could delay therapy which could have severe
consequences or both etus and mother. More
aggressive therapy or cholangitis is there ore indi-
cated in pregnancy. Although conservative treatment
with continued intravenous antibiotics and observa-
tion may be appropriate in the non-gravid patient,
the risks o this non-surgical approach are higher in
the gravid patient and predispose her to grave com-
plications. Premature delivery o the etus is not indi-
cated or the treatment o biliary disease.
BIBLIOGRAPHY
Augustin G, Majerovic M. Non-obstetrical acute abdomen
during pregnancy. Eur J Obstet Gynecol Reprod Biol. 2007;
131(1):412.
Abbasi N, Patenaude V, Abenhaim H. Management and out-
comes o acute appendicitis in pregnancy-population-based
study o over 7000 cases. BJOG. 2014 121(12):150914.
Banks PA, Freeman ML, et al. Practice Guidelines in Acute
Pancreatitis. Am J Gastroenterol. 2006;101(10):2379400.
Chen MM, Coakley FV, Kaimal A, Laros RK, Jr. Guidelines or
computed tomography and magnetic resonance imaging
http://surgerybook.net/
use during pregnancy and lactation. Obstet Gynecol. 2008;
112(2 Pt 1):33340.
Dietrich CS, Hill CC, Hueman M. Surgical diseases present-
ing in pregnancy. Surg Clin North Am. 2008;88(2):40319,
viiviii.
Gilat , Koniko F. Pregnancy and the biliary tract. Can J Gas-
troenterol. 2000; 14 Suppl D:55D9D.
Gilo NB, Amini D, Landy HJ. Appendicitis and cholecystitis in
pregnancy. Clin Obstet Gynecol. 2009;52(4):58696.
Gjelsteen AC, Ching BH, Meyermann MW, et al. C , MRI,
PE , PE /C , and ultrasound in the evaluation o obstetric
and gynecologic patients. Surg Clin North Am. 2008;88(2):
36190, vii.
Graham G, Baxi L, T arakan . Laparoscopic cholecystectomy
during pregnancy: A case series and review o the litera-
ture. Obstet Gynecol Surv. 1998;53(9):56674.
Knight M, Nelson-Piercy C, Kurinczuk JJ, Spark P, Brockle-
hurst P, UK Obstetric Surveillance System. A prospective
national study o acute atty liver o pregnancy in the UK.
Gut. 2008;57(7):9516.
Khandelwal A, Fasih N, Kielar A. Imaging o acute abdomen
in pregnancy. Radiol Clin North Am. 2013;51(6):100522.
Kim YW, Zagorski SM, Chung MH. Laparoscopic common
bile duct exploration in pregnancy with acute gallstone
pancreatitis. JSLS. 2006;10(1):7882.
Koren G, Florescu A, Costei AM, Boskovic R, Moretti ME.
Nonsteroidal antiin ammatory drugs during third trimes-
ter and the risk o premature closure o the ductus arterio-
sus: A meta-analysis. Ann Pharmacother. 2006;40(5): 8249.
Lu EJ, Curet MJ, El-Sayed YY, Kirkwood KS. Medical versus
surgical management o biliary tract disease in pregnancy.
Am J Surg. 2004;188(6):7559.
Othman MO, Stone E, Hashimi M, Parasher G. Conserva-
tive management o cholelithiasis and its complications
in pregnancy is associated with recurrent symptoms and
more emergency department visits. Gastrointest Endosc.
2012;76(3):5649.
Parangi S, Levine D, Henry A, Isakovich N, Pories S. Surgi-
cal gastrointestinal disorders during pregnancy. Am J Surg.
2007;193(2):22332.
Reiss R, Nudelman I, Gutman C, Deutsch AA. Changing
trends in surgery or acute cholecystitis. World J Surg. 1990;
14(5):56770, discussion 5701.
Walcher , Haenle MM, Kron M, et al. Pregnancy is not a risk
actor or gallstone disease: Results o a randomly selected
population sample. World J Gastroenterol. 2005;11(43):
68006.
Wallace GW, Davis MA, Semelka RC, Fielding JR. Imaging
the pregnant patient with abdominal pain. Abdom Imag-
ing. 2012;37(5):84960.
 39
Liver Metastasis

Kevin M. Lin-Hurtubise and Robert L. She er

A 60-year-old male presents with 2 months history o D. Ce uximab plus multiagent chemo (FOLFOX
rectal bleeding associated with anorexia and a 10 lbs or FOLFIRI) is best used or patients with the
weight loss. He underwent a diagnostic colonoscopy K-RAS wild type colorectal cancer.
revealing an ulcerated and circum erential right cecal E. 5-FU and leucovorin are adequate.
mass; biopsy returns as invasive adenocarcinoma. Stag-
3. Contraindications to liver surgery or metastatic
ing C scan o chest/abdomen/pelvis shows bilobar and
tumor resection include:
peripheral liver masses ranging rom 2 to 3 cm in diam-
eter with a total o 3 masses, no regional or paraaortic A. Resection that would remove 5 hepatic segments
adenopathy, and no other distant sites o disease. Percu- B. Bilobar liver involvement
taneous biopsy o a right lobar liver mass reveals meta- C. Resection that would require removal o 60% o
static adenocarcinoma, consistent with the colon as the the liver
primary site o malignancy. T e patient has hyperten- D. 4 cm liver lesion
sion and hypercholesterolemia. He has no amily his- E. umor involving the common hepatic artery
tory o colorectal cancer. His unctional status is good. 4. Af er success ul resection o both the primary
colon cancer and its liver metastases, the guidelines
1. T e best initial management in this patient is: or surveillance include:
A. Neoadjuvant chemotherapy A. Occult ecal blood testing every 6 months
B. Concomitant right hemicolectomy and liver B. CEA levels annually or the next 5 years
resection C. C scans o thorax/abdomen/pelvis every
C. Right colectomy then chemotherapy 3 months or the next 5 years
D. Radio requency ablation o liver tumors D. Surveillance colonoscopy one year a er surgery,
E. Hepatic Intraarterial chemotherapy repeat in 3 years i no advanced adenomas ound,
then every 5 years
2. Regarding neoadjuvant chemotherapy that is
E. Annual PE scan
used or metastatic colorectal cancer, which o the
ollowing statements is true? 5. For initially unresectable colorectal liver metastases,
A. XELOX (capecitabine and oxaliplatin) is less what percentage o patients will be resectable
e ective than 5-FU and leucovorin. ollowing neoadjuvant chemotherapy?
B. FOLFOXIRI (leucovorin, 5-FU, oxaliplatin, iri- A. About 5%
notecan) is recommended over FOLFIRI (5-FU, B. About 15%
leucovorin, and irinotecan). C. About 30%
C. FOLFIRI increases overall survival compared to D. About 50%
FOLFOX (5-FU, leucovorin, and oxaliplatin). E. About 70%

http://surgerybook.net/
138 G EN ERAL S U RG ERY EXAM I N ATI O N AN D BO ARD REVI EW
ANSWERS
1. B. Concomitant colon and liver resections would
be pre erable or this patient. I hepatic metasta-
ses are resectable on presentation, surgical resec-
tion should be considered rather than preoperative
chemotherapy or medically t patients with 4 or
ewer metastases. T e de nition o resectable dis-
ease encompasses both the character o the meta-
static lesions and the patient's overall health status.
T is patient has minimal co-morbidities and a good
unctional status rendering him a potentially good
candidate or major abdominal surgery. T e liver
lesions in this scenario are considered resectable
because o their overall number (4 or less), moder-
ate size (only 2 to 3 cm), and its ideal peripheral liver
location. Central or large metastatic liver lesions
(> 6 cm) that encroach upon major liver vasculature
such as the hilum o the main portal vein would pre-
clude liver resection. Un ortunately no more than
20% o patients with isolated hepatic metastases are
amenable to potential curative hepatic resection; but
because o clear survival impact, surgical resection
is the treatment o choice or resectable colorectal
metastases to the liver.
T ere is an exception i to this rule and that is,
i the metastatic tumor response to chemotherapy
is expected to create a signi cantly less complex
liver resection, then neoadjuvant therapy is rec-
ommended. T e next recommended management
option is an initial right hemicolectomy i the patient
is already exhibiting GI obstructive symptoms, ol-
lowed by our to six cycles o chemotherapy (must
be cognizant o potential hepatotoxicity i too much
chemotherapy is given), and then consideration o
liver resection i still indicated. Radio requency abla-
tion (RFA) is not considered curative or larger liver
metastases. Intra-arterial chemotherapy should be
limited to centers with expertise in this modality.
2. D. T e use o 5-FU ( uorouracil) and leucovorin
has historically been the basis o adjuvant chemo-
Chemotherapeutic
Regimen 5-FU Leucovorin
FOLFOX + +
FOLFOXIRI + +
FOLFIRI + +
XELOX
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therapy or Stage III colon cancer. Similarly or Stage
II and III rectal cancer, 5-FU and leucovorin along
with radiation therapy is recommended. Currently
or Stage III colon cancer, FOLFOX is considered
the superior regimen over 5FU-Leucovorin, with
improved survival but has additional risk o periph-
eral neuropathy. For Stage IV disease, there seems to
be increased response and better survival with the
addition o biologic agents like ce uximab, pani-
tumumab, and bevacizumab, or alkylating agents
like oxaliplatin, and topoisomerase inhibitors like
irinotecan to the 5FU-leucovorin regimen. T e
table o chemotherapeutic regimens listed below
+ /- bevacizumab or ce uximab are acceptable
or metastatic colorectal cancer treatment in the
neoadjuvant setting. 5-FU and leucovorin alone is
not adequate treatment or patients with metastatic
colorectal disease.
FOLFOXIRI when compared to FOLFIRI was
equivalent in overall survival, response rates, and
median time to disease progression. FOLFOXIRI,
however, was associated with more signi cant
side e ects. Furthermore, the addition o biologic
agents, ce uximab or panitumumab is recom-
mended or patients with colorectal tumors exhib-
iting the K-RAS wild-type, which may increase
the number o patients eligible or liver resection
post-chemotherapy (pt reevaluated or conversion
to resectable disease every 2 months) to improve
their outcomes.
For colorectal metastatic disease, FOLFOX or
FOLFIRI are considered to be equally e ective with
di erent toxicity pro le. Capecitabine is an orally
administered tumor-activated 5-FU prodrug.
3. E. Inadequate post-resection liver reserve is consid-
ered a contraindication or liver resection o colo-
rectal metastases. T at being said, in healthy livers,
up to 70% o the liver or up to 6 hepatic segments
can be resected sa ely. T e location o the tumor is
also important as metastatic tumors invading the
Oxaliplatin Irinotecan Capecitabine
+
+ +
+
+ +

common hepatic artery, common hepatic duct, main
portal vein, or > 3 hepatic veins would be consid-
ered contraindications. Extrahepatic involvement o
the celiac, portal, or paraaortic nodes would also be
considered a contraindication. Lesions larger than
6 cm would also be considered a relative contrain-
dication to resection. Bilobar disease or greater that
4 metastatic lesions that do not shrink with neoad-
juvant chemotherapy was deemed inappropriate or
liver resection based on OncoSurge statistical mod-
eling.
4. D. Surveillance is an important aspect o cancer care
in order to determine adequate initial management
and to detect early recurrences. A patient would not
be considered cured until they have survived at least
5 years a er initial therapy. T e clinical guidelines
o surveillance or colon cancer patients have been
put orth by the National Comprehensive Cancer
Network, version 1.2016. T eir recommendations
include clinical assessments every 3 to 6 months or
the rst 2 years, then every 6 months or the next
3 years. T is includes a serum CEA level at each
clinic visit. A C scan o the chest/abdomen/pelvis
is recommended every 6 to 12 months or 5 years
or patients at high risk o recurrence. Regarding
colonoscopy, one is recommended 1 year a er sur-
gery. I no lesions or a simple adenoma is ound (not
advanced such as villous polyp, polyp > 1 cm, or high
grade dysplasia), a colonoscopy should be repeated
in 3 years, and then repeated every 5 years or the
remainder o their lives. I an advanced or large
adenoma is ound (and subsequently removed com-
pletely via colonoscopy), then repeat colonoscopy is
recommended in 1 year. A PE scan is reserved or
instances were the CEA is rising or lesions are seen
on ollow up C scanning. Fecal occult blood testing
is not required or surveillance.
5. A. About 5% o patients will bene t rom neoadju-
vant chemotherapy in terms o ability to resect liver
metastases. wo randomized studies, the CRYS AL
and OPUS trials, showed modest improvement o
liver resection rates rom 3.7% to 7% and 2.4% to
4.7%, respectively with the use o the biologic agent
ce uximab to FOLFOX or FOLFIRI versus FOLFOX
or FOLFIRI alone. When the analysis was limited
http://surgerybook.net/
C H AP TER 3 9 LIVER M ETAS TAS IS 139
only to (liver) metastatic pts with wild-type KRAS,
resectability was increased rom 4% to 10%.
BIBLIOGRAPHY
Adam R, Aloia , Levi F, et al. Hepatic resection a er rescue
ce uximab treatment or colorectal liver metastases, pre-
viously re ractory to conventional systemic therapy. J Clin
Oncol. 2007;25(29):4593-602.
Andre , Boni C, Navarro M, et al. Improved overall survival
with oxaliplatin, uorouracil, and leucovorin as adjuvant
treatment in stage II or III colon cancer in the MOSAIC
trial. J Clin Oncol. 2009;27(19):3109-116.
Blazer D, Kishi Y, Maru DM, et al. Pathologic response to pre-
operative chemotherapy: a new outcome end point a er
resection o hepatic colorectal metastases. J Clin Oncol.
2008;26(33);5344-51.
Bokemeyer C, Bondarenko I, Hartmann J , et al. Ef -
cacy according to biomarker status o ce uximab plus
FOLFOX-4 as rst-line treatment or metastatic colorectal
cancer: the OPUS study. Ann Oncol. 2011; 22(7): 1535-46.
Bokemeyer C, Bondarenko I, Makhson A, et al. Fluorouracil,
leucovorin, and oxaliplatin with and without ce uximab
in the rst-line treatment o metastatic colorectal cancer.
J Clin Oncol. 2009;27(5):663-71.
Carpizo D, Are C, Jarnagin W, et al. Liver resection or meta-
static colorecatl cancer in patients with concurrent extra-
hepatic disease: Results in 127 patients treated at a single
center. Ann Surg Oncol. 2009;16(8):2138-46.
Colucci G, Gebbia V, Paoletti G, et al. Phase III randomized
trial o FOLFIRI versus FOLFOX-4 in the treatment o
advanced colorectal cancer: a multicenter study o the
Gruppo Oncologico DellLtalia Meridionale. J Clin Oncol.
2005;23(22):4866-75.
Martin R, Augenstein V, Reuter NP, et al. Simultaneous versus
staged resection or synchronous colorectal cancer liver
metastases. J Am Coll Surg. 2009;208(5):842-50.
Network NC. (n.d.). NCCN clinical practice guidelines in
oncology, version 1.2016. Retrieved Nov 6, 2015, rom
http://www.nccn.org/pro essionals/physician_gls/ _guide-
lines.asp
Poston G, Adam R, Alberts S, et al. OncoSurge: a strategy or
improving resectability with curative intent in metastatic
colorectal cancer. J Clin Oncol. 2005;23(28);7125-34.
Reddy S, Pawlik M, Zorzi D, et al. Simultaneous resections o
colorectal and synchronous liver metastases: a multi-insti-
tutional analysis. Ann Surg Oncol. 2007;14(12);3481-91.
Souglakos J, Androulakis N, Syrigos K, et al. FOLFOXIRI v.
FOLFIRI as rst-time treatment in metastatic colorectal
cancer: a multicenter, randomized phase III trial rom the
Hellenic Oncology Research Group (HORG). Br J Cancer.
2006;94(6):798-805.
Van Custem E, Kohne CH, Hitre E, et al. Ce uximab and che-
motherapy as initial treatment or metastatic colorectal
cancer. N Eng J Med. 2009;360(14):1408-17.
 40
Liver Cirrhosis
Richard Smith
A 55-year-old man with a known history o cirrhosis sec-
ondary to alcohol (E OH) abuse presents with a several
month history o an increasing umbilical bulge. On exam
he had a reducible umbilical hernia with a 3 cm ascial
de ect and shi ing dullness and a uid wave complete with
moderate ascites. He denies any symptoms other than mild
discom ort at the hernia. He denies any previous episodes
o GI bleed. History, physical exam, and serum laboratory
evaluation o the above patient shows a Child- urcotte-
Pugh classi cation o 9 points or class B and a MELD score
o 10. His platelets are 160,000, HGB is 12 g/dL, sodium
level is 135 MeQ/L, and albumin is 3.0 ng/dL.
1. Regarding evaluation and management o this
patients ascites, which o the ollowing is true?
A. Variceal bleeding is the most common complica-
tion o cirrhosis.
B. Paracentesis is the rst step in the evaluation o
this patient.
C. Cessation o E OH once ascites develops will
have little impact on controlling ascites.
D. Ascites is re ractory in less than 5% o patients
with ascites secondary to cirrhosis.
E. Use o non-steroidal anti-in ammatory drugs
(NSAID), angiotensin converting enzyme (ACE)
inhibitors, and angiotensin receptor blocking
(ARB) drugs can prevent the progression to
renal ailure.
2. Regarding umbilical hernia repair in patients with
cirrhosis, which o the ollowing is true?
A. Incidence o umbilical hernia is 20% in patients
with cirrhosis and ascites.
http://surgerybook.net/
B. Large volume paracentesis (LVP) decreases the
risk o incarceration or umbilical hernias in the
setting o re ractory ascites.
C. Non-operative management o patients with
umbilical hernia and ascites is the pre erred
management because o the morbidity and mor-
tality associated with surgery.
D. Use o synthetic mesh is contraindicated in
repair o umbilical hernias in patients with cir-
rhosis and ascites.
E. Complication rates are signi cantly higher in
elective repair o umbilical hernia in cirrhotics
when compared to non-cirrhotics.
3. Regarding morbidity and mortality in non-hepatic
surgery in patients with liver cirrhosis, which
statement is true?
A. Open surgery is pre erred to laparoscopic sur-
gery because o the concern or increased
bleeding ollowing laparoscopic procedures in
cirrhotics.
B. Elective pancreatic surgery in C P class A and B
has acceptable morbidity and mortality.
C. Elective inguinal hernia repair is indicated or
symptomatic inguinal hernias even in advanced
liver disease with decompensated cirrhosis.
D. Morbidity and mortality are higher or all sur-
gical procedures in patients with liver cirrhosis
when compared to patients without cirrhosis.
4. T e above patient presents to the emergency
room several days a er your evaluation with
ever, abdominal pain, and ileus. His vitals are a

temperature o 101F, heart rate o 90, and a systolic
blood pressure o 100. On exam he is di usely
tender, without exam evidence o peritonitis,
and has increased ascites. Plain f lms o the chest
and abdomen show an ileus pattern, without
obstruction and no ree intraperitoneal air.
Your working diagnosis is spontaneous bacterial
peritonitis (SBP). Which o the ollowing is true?
A. Administration o broad spectrum antibiotics as
the rst step is necessary to avoid circulatory col-
lapse and hepatorenal syndrome.
B. SBP is associated with the nding o multiple
organisms on paracentesis culture.
C. Ascitic uid analysis would expect to show neu-
trophils > 250/mm 3 with lactate dehydrogenase
greater than the upper limit o normal or serum,
glucose less than 50 mg/dL and ascitic protein
> 1 g/dL.
D. Administration o 1.5 g/kg o albumin on admis-
sion and 1 g/kg on day 3 has been shown to
decrease mortality.
E. A positive peritoneal culture is necessary or
diagnosis.
5. T e above patient undergoes elective umbilical
hernia repair. On the day 3 a er the operation, he
develops hematemesis and hypotension. Based on
the most likely etiology o his upper gastrointestinal
hemorrhage, which o the ollowing is true?
A. Propranalol plays an important role in the acute
management o this problem by decreasing
splanchnic blood ow.
B. rans usion to a HGB o 10 is the goal o resusci-
tation.
C. Antibiotic therapy is an important component.
D. rans-jugular intra-hepatic shunt ( IPS) proce-
dures have no role in the acute setting.
E. Pharmacologic therapy should not be started
until varices are con rmed by esophagastroduo-
denoscopy (EGD).
ANSWERS
1. B. T e cessation o alcohol usually leads to improve-
ment in liver unction with alcohol associated cirrho-
sis. One study ound improvement o the ChildPugh
score was observed within 3 months in 66% o the
abstinent patients. Ascites is the most common com-
plication o cirrhosis with 50% o compensated cir-
rhotics developing ascites over the course o 10 years.
http://surgerybook.net/
C H AP TER 4 0 Li v ER C i RRH o s i s 14 1
Paracentesis with appropriate ascitic uid analysis is
the rst step in the evaluation o clinically apparent
ascites. T e serum-ascites albumin gradient (SAAG)
with a value 1.1 g/dL is indicative o portal hyper-
tension. Medical management with salt restriction
and diuretics is highly e ective in most patients with
ascites. Re ractory ascites occurs in less than 20% o
patients. T e use o ACE inhibitors and ARB drugs
can induce renal ailure and hypotension increasing
mortality in patients with ascites. NSAIDs impair
glomerular ltration rate due to a reduced renal per-
usion secondary to inhibition o renal prostaglandin
synthesis leading to renal ailure.
2. A. Umbilical hernia is present in 20% o patients
with cirrhosis and this is 10 times higher than the
incidence in the overall population. T e increased
incidence is related to ascites, abdominal wall atten-
uation, and malnutrition. A sudden decrease in the
amount o ascites, as with transjugular intrahe-
patic portosystemic shunt ( IPS) or LVP, can lead
to strangulation o an incarcerated umbilical her-
nia. Non-operative management is associated with
higher mortality when compared to elective repair.
T e higher mortality is related to the development
o bowel incarceration or spontaneous rupture rom
necrosis o overlying skin and subsequent peritonitis
developing during watch ul waiting. T ese com-
plications orce prompt elective repair in patients
who are at very high risk or death with emergency
surgery. A randomized study comparing umbilical
hernia repair with or without prosthetic material in
cirrhotic patients with symptomatic, or complicated
hernia ound a decreased recurrence rate avoring
prosthetic repair. T e same study showed a non-sig-
ni cant increase in in ections in the prosthetic group
but no mesh had to be removed in any o the cases.
Morbidity in elective repair o umbilical hernia is
similar between cirrhotics and non-cirrhotics.
3. C. Patients with advanced decompensated cir-
rhosis requently have severe symptoms because o
ascites entering the hernia sac both in the standing
position and when recumbent making it dif cult to
relieve symptoms. Patients with decompensated cir-
rhosis have been shown to bene t the most in terms
o improved quality o li e and the procedures can
be done with minimal morbidity. Laparoscopic chol-
ecystectomy has been shown to be sa e in patients
with Childs- urcotte class A and B cirrhosis and is
14 2 G EN ERAL s U RG ERY EXAM i N ATi o N AN D Bo ARD REv i EW
associated with less blood loss and shorter hospital
stay when compared to open cholecystectomy. Simi-
lar bene ts are seen avoring laparoscopic appendec-
tomy over open appendectomy. T e data is limited
or patients with Childs C classi cation. Pancreatic
surgery is associated with an increased risk o post-
operative complications in patients with liver cirrho-
sis. T e mortality in Childs A patients is similar to
non-cirrhotics but the mortality or Childs B patients
is prohibitive. Although morbidity is higher or cir-
rhotics when compared to non-cirrhotics or most
procedures, some procedures such as inguinal hernia
repair have similar morbidity even or advanced liver
disease. Mortality in Childs A patients is o en airly
similar to non-cirrhotics or a variety o procedures
ranging rom pancreatic surgery to cardiac surgery.
4. D. T e use o IV albumin in cirrhotics with SBP in
addition to antibiotics has been shown to decrease
in-hospital mortality. T e e ect is more pronounced
or patients with a creatinine greater than 1 mg/dL or
a bilirubin greater than 4 mg/dL. Ascitic uid testing
should be done prior to the initiation o antibiotics
because 86% o cultures will be negative even a er
a single dose o antibiotics. T e nding o multiple
organisms rom a diagnostic paracentesis should
prompt consideration o a secondary peritonitis
not SBP. T e ndings o neutrophils > 250/mm 3
with lactate dehydrogenase greater than the upper
limit o normal or serum, glucose less than 50 mg/
dL and ascitic protein > 1 g/dL are associated with
secondary peritonitis. A cirrhotic patient with signs
and symptoms o SBP should be treated empirically
regardless o culture results. T e cultures are impor-
tant or narrowing o antibiotic coverage given the
increasing emergence o resistant organisms.
5. C. Variceal bleeding accounts or 70% o all upper
gastrointestinal bleeding in patients with cirrhosis.
Antibiotic prophylaxis in cirrhotic patients with gas-
trointestinal bleeding has been shown to decrease the
risk o bacterial in ections, re-bleeding and overall
mortality. Nonselective beta-blockers (propranolol)
do reduce portal blood ow by decreasing cardiac
output (-1 e ect) and, more importantly, by produc-
ing splanchnic vasoconstriction (-2 e ect) and play
a role in prevention o variceal bleeding. However,
they should not be used in the acute setting as they
will decrease blood pressure and will blunt a physi-
ologic response to bleeding. T e goal or trans usion
http://surgerybook.net/
is to a hemoglobin o approximately 78 g/dL. T is
is based on studies showing aggressive restoration
o blood volume leads to increases in portal pres-
sure and subsequent rebleeding and mortality. IPS
procedures are very e ective in controlling bleeding
in the 10% to 20% o patients who ail pharmaco-
logic and endoscopic therapy. Early placement o
IPS within 24 to 48 hours a er admission has been
shown to improve survival in patients at the high-
est risk o re-bleeding (Childs C and patients with
a hepatic venous pressure gradient (HVPG) over
20 mm Hg). Vasoconstrictor therapy (vasopressin
nitroglycerin, terlipressin, somatostatin, or octreo-
tide) is considered rst-line therapy and should be
started at the time o admission in any patient with
suspected variceal hemorrhage even prior to EGD.
BIBLIOGRAPHY
Akriviadis EA, Runyon BA. Utility o an algorithm in di er-
entiating spontaneous rom secondary bacterial peritoni-
tis. Gastroenterology. 1990;98(1):12733.
Ammar SA. Management o complicated umbilical hernias
in cirrhotic patients using permanent mesh: Randomized
clinical trial. Hernia. 2010;14(1):3538.
Bernard B, Grange JD, Khac EN, Amiot X, Opolon P, Poynard
. Antibiotic prophylaxis or the prevention o bacterial
in ections in cirrhotic patients with gastrointestinal bleed-
ing: A meta-analysis. Hepatology. 1999;29(6):165561.
Belghiti J, Durand F. Abdominal wall hernias in the setting o
cirrhosis. Semin Liver Dis. 1997;17(3):21926.
de Goede B, Klitsie PJ, Lange JF, Metselaar HJ, Kazemier G.
Morbidity and mortality related to non-hepatic surgery in
patients with liver cirrhosis: A systematic review. Best Pract
Res Clin Gastroenterol. 2012;26(1):4759.
Dokmak S, Aussilhou B, Belghiti J. Umbilical hernias and cir-
rhose. J Visc Surg. 2012;149(5 Suppl):e329.
Eker HH, van Ramshorst GH, de Goede B, et al. A prospective
study on elective umbilical hernia repair in patients with
liver cirrhosis and ascites. Surgery. 2011;150(3):5426.
El-Awadi S, El-Nakeeb A, Yousse , et al. Laparoscopic versus
open cholecystectomy in cirrhotic patients: A prospective
randomized study. Int J Surg. 2009;7(1):669.
European Association or the Study o the Liver. EASL clinical
practice guidelines on the management o ascites, sponta-
neous bacterial peritonitis, and hepatorenal syndrome in
cirrhosis. J Hepatol. 2010;53(3):397417.
Gines P, Quintero E, Arroyo V, et al. Compensated cirrhosis:
Natural history and prognostic actors. Hepatology. 1987;
7(1):1228.
Garcia- sao G, Sanyal AJ, Grace ND, Carey W, Practice
Guidelines Committee o the American Association or the
Study o Liver Diseases, Practice Parameters Committee
o the American College o Gastroenterology. Prevention
and management o gastroesophageal varices and variceal
hemorrhage in cirrhosis. Hepatology. 2007;46(3):92238.

Garcia-Pagan JC, Caca K, Bureau C, et al. Early use o IPS in
patients with cirrhosis and variceal bleeding. N Engl J Med.
2010;362(25):23709.
Gray SH, Vick CC, Graham LA, Finan KR, Neumayer LA,
Hawn M . Umbilical herniorrhapy in cirrhosis: Improved
outcomes with elective repair. J Gastrointest Surg. 2008;
12(4):67581.
Liou IW. Management o end-stage liver disease. Med Clin
North Am. 2014;98(1):11952.
Marsman HA, Heisterkamp J, Halm JA, ilanus HW, Metse-
laar HJ, Kazemier G. Management in patients with liver
cirrhosis and an umbilical hernia. Surgery. 2007;142(3):
3725.
Patti R, Almasio PL, Buscemi S, Fama F, Craxi A, Di Vita
G. Inguinal hernioplasty improves the quality o li e in
patients with cirrhosis. Am J Surg. 2008;196(3):3738.
Perez-Ayuso RM, Arroyo V, Planas R, et al. Randomized
comparative study o ef cacy o urosemide versus spi-
ronolactone in nonazotemic cirrhosis with ascites. Rela-
tionship between the diuretic response and the activity
o the renin-aldosterone system. Gastroenterology. 1983;
84(5 Pt 1):9618.
Puggioni A, Wong LL. A metaanalysis o laparoscopic chole-
cystectomy in patients with cirrhosis. J Am Coll Surg. 2003;
197(6):9216.
Runyon BA, AASLD. Introduction to the revised american
association or the study o liver diseases practice guideline
management o adult patients with ascites due to cirrhosis
2012. Hepatology. 2013;57(4):16513.
http://surgerybook.net/
C H AP TER 4 0 Li v ER C i RRH o s i s 14 3
Runyon BA, Montano AA, Akriviadis EA, Antillon MR, Irving
MA, McHutchison JG. T e serum-ascites albumin gradient
is superior to the exudate-transudate concept in the di -
erential diagnosis o ascites. Ann Intern Med. 1992;117(3):
21520.
Stanley MM, Ochi S, Lee KK, et al. Peritoneovenous shunting
as compared with medical treatment in patients with alco-
holic cirrhosis and massive ascites. Veterans administra-
tion cooperative study on treatment o alcoholic cirrhosis
with ascites. N Engl J Med. 1989;321(24):16328.
Sort P, Navasa M, Arroyo V, et al. E ect o intravenous albu-
min on renal impairment and mortality in patients with
cirrhosis and spontaneous bacterial peritonitis. N Engl J
Med. 1999;341(6):4039.
elem DA, Schiano , Divino CM. Complicated hernia pre-
sentation in patients with advanced cirrhosis and re rac-
tory ascites: Management and outcome. Surgery. 2010;
148(3):53843.
rotter JF, Suhocki PV. Incarceration o umbilical hernia ol-
lowing transjugular intrahepatic portosystemic shunt or
the treatment o ascites. Liver Transpl Surg. 1999;5(3):
20910.
Warnick P, Mai I, Klein F, et al. Sa ety o pancreatic surgery in
patients with simultaneous liver cirrhosis: A single center
experience. Pancreatology. 2011;11(1):2429.
Veldt BJ, Laine F, Guillygomarch A, et al. Indication o liver
transplantation in severe alcoholic liver cirrhosis: Quan-
titative evaluation and optimal timing. J Hepatol. 2002;
36(1):938.
 41
Pancreatitis and Pancreatic Cysts
Kiran Lagisetty
A 56-year-old male presents to the emergency depart-
ment complaining o acute onset o intense boring epi-
gastric pain radiating to his back. He is unable to nd a
com ortable position in which to lie in bed. His labora-
tory analysis is signi cant or a serum lipase o 1300,
serum glucose o 260 mg/dL, LDH o 375 IU/L, AS o
350 IU/L, and WBC o 18k.
1. In order to diagnose acute pancreatitis 2 out o 3
which o the ollowing criteria are required?
A. Epigastric pain, radiologic evidence o pancreati-
tis, serum lipase at least 2 times normal.
B. Epigastric pain, radiologic evidence o pancreati-
tis, serum amylase at least 3 times normal.
C. Cholelithiasis, radiologic evidence o pancreati-
tis, serum lipase at least 3 times normal.
D. Epigastric pain, cholelithiasis, serum lipase at
least 2 times normal.
2. Which o the ollowing enzymes has been
implicated in the etiology o pancreatitis?
A. Pepsin
B. rypsin
C. Gastrin
D. Lipase
3. Which o the ollowing conditions is most likely
the etiology o our patients condition?
A. Serum triglyceride level o > 1000 mg/dL
B. Cholelithiasis
C. HIV in ection
D. Pancreatic head mass
E. Seat belt sign ollowing MVA
http://surgerybook.net/
4. Which o the ollowing conditions associated with
acute pancreatitis increases the mortality rate
rom 1%to 1020%?
A. Necrosis o greater than 1/3 o the pancreas
B. Distant organ ailure
C. Development o local complications (hemor-
rhage, abscess, pseudocyst)
D. All o the above
5. A 7 cm acute peripancreatic uid collection was
identi ed on CT scan shortly af er admission. It
was managed expectantly and a repeat CT scan
was obtained 6 weeks af er admission. Which
o the ollowing would be criteria or surgical
management o a pseudocyst?
A. T ere is no evidence o malignancy on C and
only a simple 5 cm pseudocyst persists.
B. Decrease in size rom 7 cm to only 4 cm or less
than hal its original size.
C. Decrease in size rom 7 cm to 4 cm with persis-
tence o abdominal pain.
D. Cholelithiasis
E. No communication between the pseudocyst and
a pancreatic duct such that the pseudocyst can-
not drain.
ANSWERS
1. B. At least two o the ollowing criteria are required
to diagnose acute pancreatitis: Characteristic abdom-
inal pain, radiologic evidence o pancreatitis, and/or
serum amylase or lipase level at least 3 times normal.
 C H AP TER 4 1 PAn C REATi Ti s An d PAn C REATi C C y s Ts
2. B. rypsin
3. B. Each o the above conditions is known to cause
pancreatitis. T e most common etiologies are gall-
stone and alcohol related. Hypertriglyceridemia
> 1000 mg/dL is the third most common. Other
known causes o acute pancreatitis include HIV
in ection, certain medications, carcinoma, parasites,
and trauma.
4. D. Mild acute pancreatitis is associated with a
mortality rate o about 1%. Acute pancreatitis in
conjunction with any o the listed complications is
considered severe acute pancreatitis and increases
the mortality rate to 10% to 20%; necrosis o greater
than one third o the pancreas, organ ailure to
include a systolic blood pressure 90 mm Hg, serum
creatinine > 2.9 mg/dL, gastrointestinal blood loss
> 500 mL within a 24 hr period o time, or PaO2< or
= 60 mm Hg. T e development o an abscess or
http://surgerybook.net/
14 5
pseudocyst also represents severe acute pancreatitis
and thus, also increases the mortality rate.
5. C. Approximately 50% o pancreatic pseudocysts
will resolve spontaneously af er about 4 to 6 weeks
and should there ore be managed expectantly.
Repeat C scan af er 6 weeks should be obtained to
ensure the pseudocyst is resolving. Indications or
intervention are clinical symptoms, cyst enlargement
or persistence over 6 cm, ductal communication, and
suspected malignancy. An interval o 6 weeks is gen-
erally recommended to give time or the pseudocyst
wall to mature into a thick, brous rind. T e pres-
ence o cholelithiasis is not an indication or opera-
tive intervention o a pancreatic pseudocyst.
BIBLIOGRAPHY
Beger H, Matsuno S, and Cameron J. Diseases o the Pancreas:
Current Surgical T erapy, Springer, 2008.
 42
Head o Pancreas Mass
Richard Smith
A 60-year-old male with no signi cant medical history
except a long history o smoking presents with painless
jaundice o 1 week duration. He denies any symptoms
o obstruction, weight loss, or atigue. Initial labs show
mild elevation in transaminases to less than 1.5 times
normal values and a bilirubin o 8 mg/dL. A right upper
quadrant (RUQ) ultrasound was obtained that shows
dilated intra and extra-hepatic bile ducts and a dilated
gallbladder without stones. T e pancreas is not well vis-
ualized secondary to overlying bowel gas.
1. What would be the next best step in the evaluation
o this patient?
A. Magnetic Resonance Cholangiopancreatigram
(MRCP).
B. T in slice C scan with arterial and venous
phases.
C. Whole body Positron Emission omography
(PE ) scan.
D. Endoscopic Retrograde Cholangiopancreatigra-
phy (ERCP).
E. CA19-9 laboratory specimen.
2. T e above patient is ound to have a 2 cm mass
in the head o the pancreas with no evidence
o vascular invasion, adenopathy or metastatic
disease on C scan. His CA19-9 level is mildly
elevated to 1.5 times the normal level. What is the
next most appropriate step?
A. PE scan to evaluate or occult disease.
B. ERCP and stenting o the bile duct.
C. EUS and FNA biopsy o the mass.
D. Pancreaticoduodenectomy within the next
2 weeks.
http://surgerybook.net/
E. Diagnostic laparoscopy to evaluate or occult
metastases.
3. T e above patient is instead noted to have a 3 cm
mass in the head o the pancreas that abuts greater
than 180 degrees o the superior mesenteric vein
(SMV) with occlusion o a short segment. T ere is no
evidence o metastatic disease. Endoscopic ultrasound
(EUS)-guided f ne needle aspiration (FNA) biopsy
was obtained showing adenocarcinoma. What is the
most appropriate management or this patient?
A. Initiation o neo-adjuvant chemoradiation ol-
lowed be reassessment or resection ollowing
neo-adjuvant therapy.
B. Pancreaticoduodenectomy with resection and
reconstruction o the involved SMV ollowed by
adjuvant chemoradiation.
C. Initiation o palliative chemotherapy or unre-
sectable pancreatic cancer.
D. Per ormance o prophylactic surgical biliary and
gastric bypasses prior to initiating palliative che-
motherapy.
4. Which o the ollowing is not true o patients
undergoing neo-adjuvant therapy or adenocar-
cinoma o the pancreas when compared to patients
undergoing up ront resection?
A. Signi cantly ewer patients undergoing neo-
adjuvant ultimately undergo surgery.
B. Signi cantly lower rate o lymph node positivity
in patients undergoing resection ollowing neo-
adjuvant therapy.
C. Signi cantly increased overall survival ollowing
resection a er neo-adjuvant therapy.

D. Signi cantly increased rate o R0 resections in
patients undergoing neo-adjuvant therapy.
E. Signi cantly decreased local recurrence rate in
patients undergoing neo-adjuvant therapy.
5. Which statement is true regarding operative
management in patients undergoing pancreati-
coduodenectomy?
A. Pancreaticogastrostomy has been shown con-
sistently to have a lower incidence o pancreatic
leak than pancreaticojejunostomy.
B. External drainage o pancreaticojejunostomy
has been shown to decrease pancreatic leak
rate.
C. Octreotide has been shown consistently to
decrease the incidence o clinically signi cant
pancreatic leak rate.
D. Internal drainage o pancreaticojejunostomy has
been shown to decrease pancreatic stula rate.
E. Extended lymphadenectomy has been shown to
increase overall survival.
ANSWERS
1. B. Given the lack o stones, painless presentation
and age o the patient the most likely etiology is a
peri-ampullary neoplasm. Abdominal C scan with
arterial and venous phases and 1 mm slices is the
modality o choice or identi ying pancreatic tumors,
hepatic metastases and determining resectability.
Magnetic resonance cholangiopancreatography
(MRCP) is most use ul in evaluating ductal anatomy
such as in cases o intra-ductal papillary mucinous
neoplasm (IPMN) or i choledocholithiasis is sus-
pected. MRCP is not as accurate as thin cut C scan
in determining resectability. A PE scan is not stand-
ard preoperative evaluation or a resectable lesion
and unless combined with a thin slice dual phase C
scan, is not as good as thin cut C scan in determin-
ing resectability. ERCP sensitivity or diagnosis o a
pancreas mass is no better than imaging and it has
largely been replaced by EUS and FNA biopsy when
tissue is needed because o low sensitivity or brush-
ings in pancreatic cancer. CA19-9 level is correlated
to the size o a pancreatic adenocarcinoma and can
miss small tumors and is elevated in benign causes.
It is correlated with extent o disease and can be used
to guide diagnostic laparoscopy and thus would
be appropriate to draw once a pancreatic mass is
identi ed.
http://surgerybook.net/
C H AP TER 4 2 H EAd o f PAn C REAs MAs s 14 7
2. D. Patients who are suitable operative candidates
with a resectable solid mass in the head o the pan-
creas and no evidence o metastatic disease on thin
slice C scan can proceed with resection without
additional work up. PE scan is not currently rec-
ommended as standard preoperative evaluation in
resectable pancreatic cancer. Preoperative biliary
stent drainage is associated with stent related compli-
cations and post-operative in ectious complications
and is not routinely recommended. Biliary drainage
should be considered when there will be a signi cant
delay in surgery such as in malnourished patients or
in patients undergoing neo-adjuvant therapy. When
a stent is placed, covered metal stents have shown
better patency than plastic stents and are removable
at time o surgery. Routine biopsy o a pancreatic
mass should be avoided because o a signi cant alse
negative rate, potential complications, and a small
but not insigni cant alse positive rate. No prospec-
tive trial has shown bene t in laparoscopic staging
over thin slice C scanning and it exposes patient to
two procedures under general anesthesia. However,
a selective approach or staging laparoscopy may be
undertaken in patients known to be at higher risk
or metastases. T ese patients include tumors greater
than 3 cm, tumors o body/tail and very high CA19-9
levels.
3. A. T e above example is a borderline resectable
pancreatic cancer and technically resectable with
resection o a segment o the SMV. However this is
likely to result in a positive resection margin and
would potentially bene t rom neo-adjuvant therapy
to improve the R0 resection chances. Resectability is
determined by the degree o involvement o the sur-
rounding vessels by the tumor. T ere are three cat-
egories: resectable, borderline resectable, and locally
advanced. T e borderline resectable group is usually
the hardest to de ne but in general represents a lesion
that is resectable but runs a high risk o having a mar-
gin positive resection. wo major pancreatic surgery
groups, the MD Anderson Cancer Center (MDACC)
and a consortium o the American Hepatopancrea-
ticobiliary Association (AHPBA)/Society o Surgical
Oncology (SSO)/National Comprehensive Cancer
Network (NCCN), have attempted to de ne what
constitutes each category. However, the two groups
are not in agreement in what is resectable and what
is borderline resectable. In general, the MDACC cat-
egories require greater vessel involvement to meet
14 8 G En ERAL s U RG ERY EXAM I n ATI o n An d Bo ARd REVI EW
borderline resectable criteria. T e involvement o
greater than 180 degrees involvement o the SMV in
this case would be considered borderline resectable
under both de nitions. wo meta-analyses o retro-
spective data show similar survival o patients under-
going portal/SMV resections to patients undergoing
Whipple without vein resection.
However, i the tumor in ltration involves 50%
or more o the vascular circum erence the survival
is decreased when compared to patients not requir-
ing venous resection. T e extent o disease in this
patient is not unresectable and an acceptable opera-
tive candidate should not be relegated to only pallia-
tive therapy. T e use o endoscopic biliary drainage
has largely replaced surgical bypass procedures or
biliary obstruction. Multiple studies have shown that
endoscopic biliary drainage has identical success and
short term e cacy as surgical bypass with decreased
morbidity, costs, and hospital stay. In addition, metal
stents have increased long term patency when com-
pared to plastic stents. In contrast to obstruction o
the biliary system which occurs in 80% o patients,
duodenal obstruction occurs in only 20% o patients
with peri-ampullary tumors. In act, when duodenal
palliation is necessary endoscopic therapy has been
shown to have shorter operative time, shorter hospi-
talization with more rapid resumption o oral intake,
with no di erence in morbidity or mortality when
compared to surgical bypass.
4. C. T ere are no randomized trials showing a superi-
ority o neo-adjuvant therapy over adjuvant therapy
regarding median or overall survival. When neo-
adjuvant therapy is used, signi cantly ewer patients
will ultimately undergo surgery when compared to
similar patients with borderline resectable disease
who do not undergo neo-adjuvant therapy because o
disease progression. T is is elt to be one o the major
bene ts o neo-adjuvant therapy by sparing patients
rom major surgery that was not going to be suc-
cess ul because o aggressive disease. Neo-adjuvant
therapy has shown to signi cantly reduce the nding
o node positive disease at resection when compared
to patients taken directly to surgery. Neo-adjuvant
therapy has also consistently shown an improved
R0 resection rate when compared to patients taken
directly to surgery and is the rationale or applying
neo-adjuvant therapy to patients with borderline
resectable disease. As expected with an improved
R0 resection rate and decreased nodal positivity,
http://surgerybook.net/
the local recurrence rate is signi cantly decreased.
Un ortunately none o these improvements in local
control has translated to improved survival.
5 B. Pancreatic stula is the most requent complica-
tion a er pancreatic surgery. External drainage o the
main pancreatic duct placed intra-operatively during
pancreaticoduodenectomy has been shown in several
randomized trials to decrease the rate o pancreatic
stula and hospital stay. T is is in contrast to a pro-
spective randomized trial that ound no bene t to
placement o an internal stent in the main pancreatic
duct ollowing pancreaticoduodenectomy. T e major-
ity o randomized studies, systematic reviews, and
meta-analyses have shown no di erence in outcome
with respect to the occurrence o postoperative pan-
creatic stula based on pancreaticojejunostomy versus
pancreaticogastrostomy. A single multi-center trial
did show a decrease in the pancreatic stula rate with
pancreaticogastrostomy but no di erence in overall
complication rate, length o stay or mortality. T e use
o octreotide to reduce the rate o pancreatic stula
has been extensively studied including prospective
randomized trials and meta-analyses with conf icting
results. A recent Cochrane review (Cochrane Data-
base Syst Rev. 2013; 4: CD008370) did nd an overall
decrease in pancreatic leak rate and complications or
the use o octreotide but no di erence in length o
stay or mortality. T e studies in the Cochrane review
that controlled or signi cant pancreatic leak ound
no decrease with the use o octreotide.
BIBLIOGRAPHY
Brunner B, Grabenbauer GG, Meyer , Golcher H, Sauer R,
Hohenberger W. Primary resection versus neoadjuvant
chemoradiation ollowed by resection or locally resectable
or potentially resectable pancreatic carcinoma without dis-
tant metastasis. A multi-centre prospectively randomised
phase II-study o the interdisciplinary working group gas-
trointestinal tumours (AIO, ARO, and CAO). BMC Cancer.
2007;7:41.
Conrad C, Fernandez-Del Castillo C. Preoperative evalua-
tion and management o the pancreatic head mass. J Surg
Oncol. 2013;107(1):2332.
Fernandez-Cruz L, Jimenez Chavarria E, aura P, Closa D,
Boado MA, Ferrer J. Prospective randomized trial o the
e ect o octreotide on pancreatic juice output a er pancre-
aticoduodenectomy in relation to histological diagnosis,
duct size and leakage. HPB. 2013;15(5): 3929.
Fiori E, Lamazza A, Volpino P, et al. Palliative management o
malignant antro-pyloric strictures. Gastroenterostomy vs.
endoscopic stenting. A randomized prospective trial. Anti-
cancer Res. 2004;24(1):26971.

Greer SE, Pipas JM, Sutton JE, et al. E ect o neoadju-
vant therapy on local recurrence a er resection o pan-
creatic adenocarcinoma. J Am Coll Surg. 2008;206(3):
4517.
Gurusamy KS, Koti R, Fusai G, Davidson BR. Somatostatin
analogues or pancreatic surgery. Cochrane Database Syst
Rev. 2013;4:CD008370.
Hartwig W, Werner J, Jager D, Debus J, Buchler MW. Improve-
ment o surgical results or pancreatic cancer. Lancet Oncol.
2013;14(11):e47685.
Kang CM, Hwang HK, Choi SH, Lee WJ. Controversial issues
o neoadjuvant treatment in borderline resectable pancre-
atic cancer. Surg Oncol. 2013;22(2):12331.
Maire F, Sauvanet A. Palliation o biliary and duodenal
obstruction in patients with unresectable pancreatic can-
cer: Endoscopy or surgery? J Visc Surg. 2013;150(3 Suppl):
S2731.
Moss AC, Morris E, Mac Mathuna P. Palliative biliary stents or
obstructing pancreatic carcinoma. T e Cochrane Database
o Systematic Reviews 2006; (1): CD004200. doi: 10.1002/
14651858.CD004200.pub2.
Ouaissi M, Giger U, Louis G, Sielezne I, Farges O, Sastre B.
Ductal adenocarcinoma o the pancreatic head: A ocus on
current diagnostic and surgical concepts. World J Gastro-
enterol. 2012;18(24):305869.
Siddiqui AA, Mehendiratta V, Loren D, Hong SK, Kowalski .
Fully covered sel -expandable metal stents are e ective and
sa e to treat distal malignant biliary strictures, irrespective
o surgical resectability status. J Clin Gastroenterol. 2011;
45(9):8247.
Strobel K, Heinrich S, Bhure U, et al. Contrast-enhanced
18F-FDG PE /C : 1-stop-shop imaging or assessing the
http://surgerybook.net/
C H AP TER 4 2 H EAd o f PAn C REAs M As s 14 9
resectability o pancreatic cancer. J Nucl Med. 2008;49(9):
140813.
opal B, Fieuws S, Aerts R, et al. Pancreaticojejunostomy
versus pancreaticogastrostomy reconstruction a er pan-
creaticoduodenectomy or pancreatic or periampullary
tumours: A multicentre randomised trial. Lancet Oncol.
2013;14(7):65562.
van den Bosch RP, van Eijck CH, Mulder PG, Jeekel J. Serum
CA19-9 determination in the management o pancreatic
cancer. Hepatogastroenterology. 1996;43(9):71013.
van der Gaag NA, Rauws EA, van Eijck CH, et al. Preopera-
tive biliary drainage or cancer o the head o the pancreas.
N Engl J Med. 2010;362(2):12937.
Wang Q, Gurusamy KS, Lin H, Xie X, Wang C. Preoperative
biliary drainage or obstructive jaundice. Cochrane Data-
base Syst Rev. 2008; (3): CD005444. doi(3):CD005444.
Warshaw AL, Lillemoe KD, Fernandez-del Castillo C. Pancre-
atic surgery or adenocarcinoma. Curr Opin Gastroenterol.
2012;28(5):48893.
Winter JM, Cameron JL, Campbell KA, et al. Does pancreatic
duct stenting decrease the rate o pancreatic stula ollow-
ing pancreaticoduodenectomy? Results o a prospective
randomized trial. J Gastrointest Surg. 2006; 10(9):128090;
discussion 1290.
Yang SH, Dou KF, Sharma N, Song WJ. T e methods o
reconstruction o pancreatic digestive continuity a er
pancreaticoduodenectomy: A meta-analysis o random-
ized controlled trials. World J Surg. 2011;35(10):22907.
Yeoh KG, Zimmerman MJ, Cunningham J , Cotton PB. Com-
parative costs o metal versus plastic biliary stent strategies
or malignant obstructive jaundice by decision analysis.
Gastrointest Endosc. 1999;49(4 Pt 1):46671.
 43
Spleen/Idiopathic
T rombocytopenic Purpura
Ali Linsk and John Paul Sanders
A 53-year-old emale with a 3-week history o melena
presents to her primary care provider and is ound to
have scattered ecchymoses, heme-positive stool, and
a platelet count o 45,000. Colonoscopy screening was
per ormed 1 year ago and was negative. She does not
take any medications. Other than a mild anemia, labo-
ratory work-up is otherwise unremarkable. Peripheral
smear and bone marrow biopsy are negative which do
not demonstrate an underlying malignancy. She is diag-
nosed with idiopathic thrombocytopenic purpura (I P).
Despite 8 weeks o prednisone therapy and the addi-
tion o intravenous immunoglobulin (IVIG), the patient
continues to have platelet counts ranging rom 20,000 to
40,000 and ongoing mucosal bleeding. She has been sent
or a surgical consultation to discuss the possibility o
splenectomy in the setting o her steroid-re ractory I P.
1. Which o the ollowing statements characterizes
ITP?
A. Endothelial damage triggers deposition o plate-
lets and brin in small arterioles and capillaries,
leading to microvascular thrombotic events.
B. IgG autoantibodies directed against platelet brin-
ogen receptors cause increased platelet destruction
via removal by macrophages.
C. Abnormal myeloid precursor cells are hyperplas-
tic resulting in splenic sequestration o platelets
and associated thrombocytopenia.
D. Peripheral blood smears in patients with I P
show schistocytes, nucleated red blood cells, and
basophilic stippling.
E. Renal ailure and neurologic complications are
both seen in late stages o I P.
http://surgerybook.net/
2. Which o the ollowing statements about steroid-
re ractory ITP is correct?
A. Rituximab therapy can be used as an alternative to
splenectomy and has an equivalent response rate.
B. Approximately 98% o patients who undergo
splenectomy are ound to have a permanent
response with no need or urther therapy.
C. Signi cant splenomegaly is seen in I P patients
who do not respond to medical therapy.
D. Plasmapheresis is a rst-line therapy or steroid-
re ractory I P and should be initiated be ore
considering splenectomy.
E. Although initial response rate to splenectomy is
in the range o 85% to 90%, the relapse rate over
the next 5 years can be as high as 25%.
3. Regarding the preoperative and intraoperative
management o patients undergoing splenectomy
or ITP, which o the ollowing statements is correct?
A. Platelet trans usion should be initiated once
anesthesia is induced and continued into post-
operative day 1 until the platelet count rises
above 50,000.
B. Patients should be vaccinated against encap-
sulated organisms (Haemophilus inf uenzae B,
polyvalent Pneumococcus, and Meningococcus)
in the holding area just prior to surgery.
C. T e splenic hilar vessels are o en divided simul-
taneously with suture ligatures or a vascular load
on a linear stapler device.
D. Accessory spleens can be present in 10% to 30%
o patients and are most commonly ound at the
splenic hilum, the tail o the pancreas, within the
 C H AP TER 4 3 S P l EEn / Id I o PATH I C TH Ro m b o C y To P En I C P u RP u RA
splenocolic and gastrosplenic ligaments, in the
omentum, or in the paraduodenal area.
E. Laparoscopic splenectomy is less e ective than
open splenectomy in identi ying and removing
accessory spleens.
4. Which o the ollowing statements is true regarding
postoperative complications af er splenectomy or
ITP?
A. Overwhelming post-splenectomy in ection (OPSI)
is seen in approximately 5% o children and 15%
o adults, regardless o vaccination status.
B. Splenectomy is associated with an increased risk
o abdominal venous thromboembolism within
the rst 90 days a er surgery.
C. Patients with I P who are treated with medical
therapy alone are at an equivalent risk or venous
thromboembolism when compared to those
who undergo splenectomy.
D. It is standard o care or patients o all ages to
take daily prophylactic antibiotics or at least a
5-year period ollowing splenectomy.
E. Rates o bleeding and in ectious complications
are similar in I P cases that show a response to
splenectomy and in those that do not.
5. Which o the ollowing statements best characterizes
the current role o thrombopoietin (TPO) receptor
agonists in the treatment o ITP?
2. E. According to a recent consensus report on the
A. T ese agents are indicated in cases o symp-
tomatic thrombocytopenia despite multiple
rst- and second-line therapies, and commonly
induce remission o I P.
B. PO receptor agonists are e ective at increasing
platelet counts via stimulation o megakaryocyte
production in the bone marrow and can be used
preoperatively to boost platelet counts in prepa-
ration or splenectomy.
C. PO receptor agonists are commonly used in con-
junction with steroids as rst-line therapy or I P.
D. PO receptor agonists are given in the post-
operative period in order to stimulate platelet
production and increase the chances o a thera-
peutic response to splenectomy.
E. Both romiplostim and eltrombopag are com-
monly used PO receptor agonists that require
weekly intravenous in usions.
ANSWERS
1. B. I P is an acquired, immune-mediated disorder that
involves the splenic production o IgG autoantibodies.
http://surgerybook.net/
151
T ese autoantibodies target brinogen receptors on
platelets and result in subsequent clearance o the
platelets by phagocytic cells. More recently, the term
primary immune thrombocytopenia has also been
used to describe this condition, ref ecting the immune-
mediated nature o the disease and the large propor-
tion o cases that do not involve overt signs o bleeding.
In addition, research has shown that impaired platelet
production and cell-mediated e ects may also play
a role in the pathophysiology o I P. Peripheral blood
smears in cases o I P tend to be within normal limits.
T rombotic thrombocytopenic purpura ( P)
is a condition in which endothelial damage triggers
deposition o platelets and brin in small arterioles
and capillaries, leading to microvascular thrombotic
events. A patient with P will mani est a microan-
giopathic hemolytic anemia, ever, severe thrombo-
cytopenia, and will commonly su er rom neurologic
complications and renal ailure. A peripheral blood
smear will demonstrate schistocytes, nucleated red
blood cells, and basophilic stippling.
Primary myelo brosis (PMF) is a malignant dis-
order in which patients su er rom signi cant sple-
nomegaly and cytopenias. T e underlying cause o
the condition is related to hyperplasia o an abnormal
myeloid precursor cell resulting in marrow brosis
and subsequent extramedullary hematopoiesis.
investigation and management o primary immune
thrombocytopenia, 80% o patients respond to
splenectomy and this response persists in 66% o
patients through at least 5 years ollowing surgery.
Un ortunately, 20% to 30% o initial responders can
experience relapses requiring additional medical or
surgical therapy in the short- or long-term, and up to
20% o patients do not respond at all. T ese numbers
are relatively consistent in laparoscopic and open
approaches and across multiple studies.
Rituximab is used as a second-line therapy in older
patients with more co-morbidities who are not ideal
surgical candidates. It has also been used or patients
who pre er non-operative management. Rituximab
is a monoclonal antibody directed against the B-cell
sur ace protein CD20. A 40% to 50% response rate
is seen initially but relapses are common and the
response rate at 5 years is 20%.
Plasmapheresis is a rst-line therapy or P, but
is not indicated in I P. Splenomegaly should prompt
work-up or other diagnoses, as the spleen is usually
normal in size in cases o I P.
152 G En ERAl S u RG ERy EXAm In ATIo n An d b o ARd REVI EW
3. D. Accessory spleens can be present in 10% to 30% o
patients and are most commonly ound at the splenic
hilum, the tail o the pancreas, within the splenocolic
and gastrosplenic ligaments, in the omentum, or in
the paraduodenal area. Both laparoscopic and open
approaches can be e ective in identi ying accessory
spleens.
Platelet trans usion should be initiated a er the
splenic artery is ligated in order to prevent platelet
consumption. T e splenic vessels should ideally be
ligated separately, in order to prevent arteriovenous
stula ormation. Vaccination against encapsulated
organisms should be per ormed in the 2- to 4-week
period prior to surgery or 14 days a er surgery or at
the time o discharge rom the hospital. I patients
were previously on rituximab therapy, vaccinations
may need to be delayed or up to 3 months to allow
or B-cell recovery.
4. B. In a retrospective review o 9,976 patients with
I P, 1,762 who underwent splenectomy, the incidence
o thrombotic events was evaluated. An increased
risk o portal vein or mesenteric vein thrombosis was
seen in the rst 90 days a er splenectomy, but not
a er 90 days when compared to patients who under-
went medical therapy alone. T ere was an increased
risk o venous thromboembolism in both the early
and late periods in the splenectomy group.
No consensus has been reached in terms o the
bene t or duration o antibiotic prophylaxis. Studies
have shown that asplenic patients carry a li elong risk
o OPSI and this risk is highest in the rst 2 years a er
surgery. Children are at a higher risk than adults (5%
vs. 0.9%) and OPSI is reported to have a 50% mortal-
ity rate. A retrospective analysis o 233 patients with
I P who underwent splenectomy showed that, in a
10-year ollow-up period, a stable response to sple-
nectomy was associated with a lower rate o in ec-
tious and bleeding complications.
5. B. PO agonists are used or persistent thrombo-
cytopenia despite rst- and second-line medical
and surgical therapy, and they do not induce remis-
sion. T ey stimulate production o megakaryocytes
and subsequently platelets in the bone marrow by
activating the PO receptor. Upon cessation o the
medication, platelet counts begin to all again. T ese
medications are considered maintenance therapy
and require ongoing use in re ractory cases o I P.
Romiplostim is administered as a once-weekly sub-
http://surgerybook.net/
cutaneous injection and eltrombopag is given as a
once-daily pill.
PO agonists can be used in the preoperative
setting in order to boost platelet counts in prepara-
tion or splenectomy. T ey have also been used in
patients who are not good candidates or rituximab
therapy secondary to in ectious risks. Patients who
do not want to have surgery or are not good candi-
dates can also use PO agonists as chronic mainte-
nance therapy. It is not standard to use these agents
in the postoperative period unless a relapse occurs
and they do not increase the chances o responding
to a splenectomy.
BIBLIOGRAPHY
Beauchamp RD, Holzman MD, Fabian C, et al. T e spleen.
In: ownsend CM, Beauchamp RD, Evers M, et al., eds.
Sabiston extbook o Surgery: T e Biological Basis o Mod-
ern Surgical Practice. 18th ed. Philadelphia, PA: WB Saun-
ders; 2008.
Boyle S, White RH, Brunson A, Wun . Splenectomy and
the incidence o venous thromboembolism and sep-
sis in patients with immune thrombocytopenia. Blood.
2013;121(23):478290.
Mikhael J, Northridge K, Lindquist K, Kessler C, Deuson R,
Danese M. Short-term and long-term ailure o laparo-
scopic splenectomy in adult immune thrombocytope-
nic purpura patients: A systematic review. Am J Hematol.
2009;84(11):7438.
Moulis G, Sailler L, Sommet A, Lapeyre-Mestre M, Derumeaux
H, Adoue D. Rituximab versus splenectomy in persistent
or chronic adult primary immune thrombocytopenia: an
adjusted comparison o mortality and morbidity. Am J
Hematol. 2013;89(1):416.
Patel NY, Chilsen AM, Mathiason MA, Kallies KJ, Bottner
WA. Outcomes and complications a er splenectomy or
hematologic disorders. Am J Surg. 2012;204:101420.
Provan D, Stasi R, Newland AC, et al. International consensus
report on the investigation and management o primary
immune thrombocytopenia. Blood. 2010;115(2):16886.
aghizadeh M, Muscarella P. Splenectomy or hematologic
disorders. In: Cameron JL, Cameron AM, eds. Current Sur-
gical T erapy. 10th ed. Philadelphia, PA: Elsevier Saunders:
2011:4739.
Vecchio R, Marchese S, Intagliata E, Swehli E, Ferla F, Cacciola
E. Long-term results a er splenectomy in adult idiopathic
thrombocytopenic purpura: comparison between open
and laparoscopic procedures. J Laparoendosc Adv Surg
ech A. 2013;23(3):1928.
Vianelli N, Palandri F, Polverelli N, et al. Splenectomy as a
curative treatment or immune thrombocytopenia: a ret-
rospective analysis o 233 patients with a minimum ollow
up o 10 years. Haematologica. 2013;98(6):87580.
Zeng Y, Duan X, Xu J, Ni X. PO receptor agonist or chronic
idiopathic thrombocytopenic purpura. Cochrane Database
Syst Rev. 2011.
 44
Small Bowel Obstruction

Patrick Golden

You are called to the emergency room to see a 66-year- D. Immediate C scan o the abdomen and pelvis
old male with a chie complaint o abdominal pain with with PO and IV contrast.
nausea and vomiting. Reviewing his ER record reveals E. Discharge to home rom the ER with close clinic
he has a heart rate o 115, blood pressure o 145/90, and ollow up within 48 hours.
a normal temperature at 98.6F. On exam the patient
appears to be in mild distress with a distended abdomen. 2. Which o the ollowing is the most common cause
T e patient states that the pain started 48 hours be ore, o bowel obstruction?
is intermittent and crampy, and is now getting worse. He A. Small bowel ileus
states that he has been vomiting now or about the last B. Mechanical small bowel obstruction
24 hours and is unable to keep any uids down. He also C. Mechanical colonic obstruction
states that he cannot remember the last time he passed D. Acute colonic pseudo-obstruction
atus or had a bowel movement. T e patient has been E. Gastric outlet obstruction
in the ER or about hal an hour, his labs are still pend-
ing, and no imaging studies have been done. His past 3. Which o the ollowing is the most common cause
medical history is signi cant or hypertension, hyper- o mechanical small bowel obstruction?
lipidemia, chronic kidney disease, diet controlled type A. Adhesions
2 diabetes, and gout. His past surgical history is signi - B. Strictures
cant or an open appendectomy 50 years earlier and a C. Hernias
laparoscopic converted to open sigmoidectomy second- D. Gallstones
ary to diverticulosis 5 years prior. T e patient denies E. umors
ever having symptoms like this be ore.
4. wenty- our hours has now passed since the above
1. Following f uid resuscitation with two liters o patient was admitted and had an nasogastric tube
crystalloid, the heart rate downtrends to 90 and (NG) and oley catheter placed. Since that time his
the blood pressure remains normal. Which o the NG tube has put out 1.6 liters o bilious f uid and
ollowing is the next best step in management o his urinary output has been around 1.1 cc/kg/hr.
this patient? T e patients pain and physical exam only worsen
A. o the OR immediately or a diagnostic laparos- intermittently. T e mans heart rate is in the 90s
copy with possible exploratory laparotomy. and his blood pressure is holding steady. Which o
B. Admission to the surgical oor, continue IV u- the ollowing is true?
ids and per orm abdominal exams every 4 hours. A. T e presence o small-bowel ecalization on
C. Placement o a nasogastric tube and an acute C scan o the abdomen and pelvis with IV/oral
abdominal series. contrast predicts the need or an operation.

http://surgerybook.net/
15 4 G EN ERAL S U RG ERY EXAM I N ATIO N AN D BO ARD REVI EW
B. I this patient had his sigmoidectomy 4 weeks ago,
he would still be a candidate or non-operative
management.
C. An exploratory laparotomy is indicated.
D. I a laparoscopical approach is chosen within the
rst 48 hours o admission, it is more likely to be
completed without conversion.
E. One can continue observation in this patient or
up to 3 days without increasing morbidity.
5. A decision is made to proceed to surgery 24 hours
later because the patient developed a ever and
a leuokocytosis. Which o the ollowing is true
regarding surgical management?
A. T e laparoscopic approach is associated with
longer operating times.
B. T e laparoscopic approach may be associated
with decreased mortality.
C. T e rate o major complications is similar or
both the laparoscopic and open approaches.
D. T e optical view approach is recommended or
this patient.
E. T e laparoscopic approach has no e ect on post-
operative length o stay.
ANSWERS
1. C. T is patient is presenting with symptoms most
consistent with some type o bowel obstruction.
T is patient has received 2 liters o crystalloid with
an appropriate response in his heart rate but he still
requires an NG tube. Given his lack o peritoni-
tis, imaging studies are appropriate and an acute
abdominal series is adequate, especially given this
patients history o chronic kidney disease and an as
yet unknown creatinine level.
Answer A is not appropriate given that he does
not have peritonitis and his work up is not yet com-
plete. Given that he is responding to resuscitation
this patient should be given the chance to see i his
symptoms resolve with non-operative management.
Answer B is not appropriate in that this patient still
has a work up to be done with labs and imaging as
the diagnosis is still unclear at this time.
Answer D is not appropriate in that while C has
a high speci city and sensitivity or bowel obstruc-
tions and can locate points o blockage his creatinine
is unknown and with his history o kidney disease
and likely kidney injury rom dehydration a con-
trast load would not be advisable. An acute abdomi-
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nal series is ast and with care ul interpretation the
diagnosis o a small bowel obstruction can still be
made. A non-contrast C scan, however, would be
a reasonable option as it would not risk an insult to
the kidneys and it may determine an internal hernia,
which would be an indication or surgical interven-
tion. Answer E is not appropriate as this patient still
requires work up.
2. A. Small bowel ileus is, by ar, the most common
orm o intestinal dilation as it is seen af er many
surgical procedures whether they are per ormed in
the abdomen or not. T e exact etiology o the ileus
is unclear but is probably multi actorial taking into
account anesthesia and narcotic usage. Viral ileus can
also be seen in cases o gastroenteritis. Ileus is most
times sel -limited and resolves with or without NG
tube decompression and keeping the patient NPO.
Answer B, mechanical small bowel obstruction, is
the second most common cause o bowel obstruction
and, 90% o the time, is due to adhesions, hernias,
or cancer; though gallstones, bezoars, and parasitic
worms have also been reported. Mechanical colonic
obstruction, while usually more severe in its presen-
tation, only accounts or around 10% o all mechani-
cal obstructions. T e usual causes o this are cancer,
volvulus, or diverticulitis resulting in a stricture.
Answer D, Acute colonic pseudo-obstruction
is much less common and is usually seen in older,
debilitated or institutionalized patients who are on
numerous medications and answer E, gastric outlet
obstruction is a less common orm o obstruction
and is usually seen with gastric/duodenal/pancreatic
malignancies or gastic ulcers. T ese would not, how-
ever, result in intestinal dilatation.
3. A. Up until the early to mid-1900s the leading cause
o mechanical small bowel obstruction was due
to hernias but over the past century that has now
switched to postoperative adhesions accounting or
over 75% o all mechanical small bowel obstructions.
Hernias are the second most common cause o
mechanical small bowel obstructions and in the
absence o a surgical history the presence o an incar-
cerated inguinal, umbilical or incisional hernia needs
to be ruled out. T e remaining answer choices have
all been shown to cause mechanical bowel obstruc-
tions though their incidence is low.
4. E. T is patients physical exam and clinical status
is largely unchanged. As such he is a candidate or

non-operative management or up to 72 hours.
Patients who have had abdominal surgery within six
weeks be ore the episode o small bowel obstruction,
patients with signs o strangulation ( ever, tachycar-
dia, luekocytosis, metabolic acidosis, continuous
pain), and patients with irreducible hernias are NO
candidates or non-operative management. On C
scan, the lack o small bowel ecalization, ree intra-
peritoneal uid, and mesenteric edema predict the
need or urgent laparotomy. As he is not exhibiting
signs o peritonitis, ischemia, or strangulation he is
most appropriately a candidate or continued obser-
vation. I af er 72 hours, i there is no improvement
in his status, an operation is indicated. Until then
there is no increase in morbidity or mortality with
observation. T ere is no data suggesting that ear-
lier intervention with a laparoscopic approach will
reduce morbidity, mortality, or conversion rates.
5. B. In a study published in 2014 on over 9600 patients
using the National Surgical Quality Improvement
Database, laparoscopic intervention or small bowel
obstructions was shown to have decreased opera-
tive time (77.2 vs. 94.2 min) and decreased length
o stay (4.7 vs. 9.9 days). Additionally, the laparo-
scopic approach was less likely to develop major
complications, with an odds ratio o 0.7. Additionally
the laparoscopic approach showed a lower 30-day
mortality rate (1.3% vs. 4.7%). As such i the surgeon
eels com ortable, the laparoscopic approach may be
a sa er alternative or the surgical management o
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C H AP TER 4 4 S M ALL BO WEL O BS TRU C TIO N 155
small bowel obstructions. When accessing the abdo-
men in a patient with previous abdominal incisions,
the recommended technique or gaining the pneu-
moperitoneum and placing the initial trocar is via
the Hasson or open technique.
BIBLIOGRAPHY
Arnaoutakis GJ, Eckhauser FE. Small Bowel Obstruction.
In: Cameron L, Cameron AM. Cameron Current Surgi-
cal T erapy. 10th ed. Philadelphia, PA: Elsevier Saunders;
2011:937.
Di Saverio S, Coccolini F, Galati M, et al. Bologna guidelines
or diagnosis and management o adhesive small bowel
obstruction (ASBO): 2013 update o the evidence-based
guidelines rom the world society o emergency surgery
ASBO working group. World J Emerg Surg. 2013;8(1):42.
Helton WS, Fisichella, PM. Intestinal Obstruction. In: Souba
WW, Fink MP Jurkovich GJ, Kaiser LP, Pearce WH, Pem-
berton JH, et al. eds. ACS Surgery Principles and Practice.
6th ed. New York, NY: WebMD Pro essional Publishing;
2007:51434.
Kelly KN, Iannuzzi JC, Rickles AS, Garimella V, Monson JR,
Fleming FJ. Laparotomy or small-bowel obstruction:
rst choice or last resort or adhesiolysis? A laparoscopic
approach or small-bowel obstruction reduces 30-day
complications. Surg Endosc. 2014;28(1):6573.
Soper NJ. Access to Abdomen. In: Soper NJ, Scott-Conner,
Carol EH, eds. SAGES Manual: Volume 1 Basic Laparoscopy
and Endoscopy. New York: Springer, Inc., 2012.
Soybel DI, Landman WB. Ileus and Bowel Obstruction. In:
Mulholland MW, Lillemoe KD, Doherty GM, et al. eds.
Greenf elds Surgery Scientif c Principles and Practice. 5th
ed. Philadelphia, PA: Lippincott Williams & Wilkins;
2011:74872.
 45
Illicit Drug-Induced
Abdominal Pain
Bonnie B. Hunt
A 26-year-old male with no signi cant past medical his-
tory presents to the emergency room in distress, com-
plaining o chest discom ort and severe epigastric pain o
sudden onset three hours prior to presentation. T orough
history reveals cocaine abuse prior to onset o symptoms.
T e patient is tachycardic and tachypneic, physical exam
reveals a di usely tender abdomen with rigidity.
1. Which o the ollowing is true regarding
complications o stimulant drug abuse?
A. Per orated gastroduodenal ulcer is unlikely to
occur without known history o ulcer disease.
B. Acute abdominal processes are the most com-
mon complications o stimulant drug abuse.
C. An ileus is the most well-documented acute
abdominal complication o cocaine abuse.
D. Systemic vasoconstriction may cause multiple
gastrointestinal complications.
2. Which radiographic study would most readily
provide the diagnostic nding or the diagnosis in
the patient presentation above?
A. C scan
B. Abdominal ultrasound
C. Upright chest radiograph
D. Angiography
3. Af er making the diagnosis above, which o
the ollowing would be the most appropriate
intervention?
A. Fluid resuscitation, gastric decompression via naso-
gastric tube, and antibiotic therapy or H. pylori
in ection.
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B. Abdominal washout, debridement o ulcerated
tissue, and omental patch closure.
C. runcal vagotomy with pyloroplasty.
D. runcal vagotomy with antrectomy and Billroth
I or II reconstruction.
4. In addition to the surgical management o
the per orated ulcer, what, i any, adjunctive
management should be included in the patients
care?
A. Nothing, the pathophysiology is directly related
to the stimulant drug and management is
directed at repair o the acute per oration.
B. Empiric triple or quadruple therapy or
H. pylori.
C. Ulcer biopsy or H. pylori in ection, and triple
or quadruple therapy only with presence o
bacteria.
D. Pharmacologic vasodilation to reverse e ects o
stimulant physiology.
5. I a patient presents with mesenteric ischemia
secondary to stimulant drug abuse along with
peritonitis or an acidosis. Af er resuscitation,
which o the ollowing represents appropriate
management?
A. Exploratory laparotomy with resection o
necrotic bowel and vasodilation.
B. Endovascular thrombolysis and arterial stenting.
C. Operative SMA embolectomy.
D. Aortomesenteric arterial bypass.
 C H AP TER 4 5 I l l IC I T D Ru g - In D u C ED Ab D o m I n Al PAI n
ANSWERS
1. D. Illicit drugs such as cocaine and methampheta-
mine are highly addictive central nervous system
stimulants which produce a rapid euphoria sec-
ondary to elevated levels o the monoamine trans-
mitters dopamine, serotonin, and norepinephrine.
Immediate e ects o stimulant use include wake ul-
ness, increased physical activity, decreased appetite,
tachypnea, tachycardia, hypertension, and hyper-
thermia. T e most common and well-known serious
side e ects o stimulant drug abuse include cardiac
and neurologic complications such as myocardial
in arction, arrhythmias, and cerebral vascular acci-
dents, additionally pulmonary and psychiatric com-
plications are common. T ough less common, acute
abdominal complications related to both cocaine
and methamphetamine are well documented in the
medical and surgical literature. T e two most com-
monly documented gastrointestinal complications
are per orated peptic ulcer and mesenteric ischemia,
both thought to be secondary to splanchnic vasocon-
striction via activated alpha-1 receptors ollowing
rapid elevation in norepinephrine. Gastroduodenal
per oration a er stimulant drug abuse may be the
initial presentation o ulcer disease, and the clinician
should have a high index o suspicion or such when
a patient presents with acute abdomen and a history
o stimulant abuse, despite the lack o ulcer disease in
the patients history. Less commonly, methampheta-
mines can cause paralytic ileus.
2. C. T e diagnosis o per orated gastroduodenal ulcer,
in conjunction with an appropriate history, is con-
rmed by the nding o pneumoperitoneum, most
quickly visualized on the upright chest x-ray under
the hemidiaphragm(s) or on the le lateral decu-
bitus abdominal X-ray. In some cases o per orated
ulcer o the anterior duodenal wall, ree air and the
sh-eye sign may be demonstrated via ultrasound. In
approximately 25% o per orated peptic ulcer pres-
entations, ree air will not be visualized. A C scan
will demonstrate inf ammatory changes surround-
ing the per orated ulcer, and is highly sensitive or
evidence o micro-per oration ( ree air or f uid).
However, in diagnosing a per orated peptic ulcer or
which plain lm did not already reveal pneumop-
eritoneum, C scan did not demonstrate additional
diagnostic utility within the rst 6 hours. Had the
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157
patients acute abdomen also presented with hema-
tochezia in the setting o stimulant drug abuse, mes-
enteric ischemia would be higher on the di erential,
diagnosed by angiogram. In the setting o stimulant
drug abuse and an acute abdomen, it is important
or the provider to obtain imaging to evaluate or the
presence o pneumoperitoneum, indicating possible
per orated peptic ulcer.
3. B. In the absence o ree air or shock, a trial o
nonoperative management may lead to spontane-
ous closure o approximately 50% o per orations.
Non-operative management o a per orated peptic
ulcer presenting with ree air and a surgical abdo-
men would not be appropriate; surgical intervention
is indicated. With the success o medical therapy
directed toward H. pylori and gastric acid suppres-
sion, surgical goals or per orated ulcers have been
increasingly narrowed rom the traditional options
or acid-reducing operations to management o the
acute complication with omental patch closure o the
per oration, with or without primary closure. Gas-
troduodenal ulcerations presenting in conjunction
with stimulant drug abuse in particular o en occur
at a younger age and without known history o ulcer
disease. T ough the prevalence o H. pylori is still
high in stimulant-associated per orated ulcers, the
path to per oration is promoted by vasoconstriction
and ocal ischemia. Given this pathophysiology, the
indication or acid-reducing surgery remains limited
to per orations in patients who have ailed medical
therapy prior to per oration.
4. C. T e traditional approach to per orated gastrodu-
odenal ulcer, outside o stimulant drug use, presumes
that the vast majority o per orated ulcers involve
H. pylori in ection. As such, standard treatment
includes surgical management o the acute compli-
cation as well as empiric treatment or H. pylori with
triple or quadruple therapy. Standard triple therapy
or H. pylori in ection includes a proton pump inhib-
itor and dual antibiotic coverage with clarithromycin
plus amoxicillin or metronidazole; quadruple ther-
apy includes a proton pump inhibitor, dual antibiotic
coverage with tetracycline plus metronidazole, and
bismuth subsalicylate. Per orated gastroduodenal
ulcers ollowing stimulant drug abuse may occur
with or without previous symptoms o peptic ulcer
disease. Despite lack o previous symptoms, there
158 g En ERAl S u Rg ERY EXAm I n ATI o n An D b o ARD REVI EW
is evidence to show that up to 80% o these ulcers
are positive or H. pylori per intraoperative biopsy.
However, despite the potential presence o H. pylori,
a key component in the acute per oration is vasocon-
striction leading to ocal ischemia, ultimately causing
ulcer per oration in patterns di erent rom standard
ulcer behavior, notably at younger ages. Given the
potential multi actorial ulcer etiology in the set-
ting o per oration ollowing stimulant drug use,
the result o H. pylori testing on intraoperative ulcer
biopsy can direct the inclusion o triple or quadru-
ple therapy ollowing surgical intervention. Despite
the vasoconstrictive physiology in stimulant drug
related per orations, treatment recommendations
are directed at repair o the per oration rather than
vasodilation.
5. A. Acute mesenteric ischemia (AMI) may result
rom arterial occlusion via embolus or thrombus
(65%), venous occlusion (10%) or non-occlusive
etiologies (25%). Prompt diagnosis o AMI is
strongly correlated to outcomes, as a delay in inter-
vention results in morbidity up to 50%. Selective
mesenteric catheter angiography is the traditional
diagnostic gold standard, however abdominal C
angiography with intravenous contrast can pro-
vide a aster diagnosis with decreased procedural
risk to the patient. Endovascular thrombolysis
and arterial stenting can be e ective at restor-
ing splanchnic per usion in acute arterial throm-
bosis; however, acute embolic arterial occlusions
typically do not respond to thrombolytic therapy
(which may also result in secondary distal emboli-
zation rom ragmented portions o the embolus),
and require laparotomy with SMA embolectomy.
Splanchnic vasoconstriction secondary to cat-
echolamine release in stimulant drug use is a rare
cause o acute non-occlusive mesenteric ischemia
(ANOMI), and impacts the major arterial sources
o bowel per usion, the SMA and IMA, as well as
smaller collaterals. hrombolysis, embolectomy,
and bypass have no role in the management o
these cases. Intra-arterial vasodilator therapy can
be e ective at restoring bowel per usion. Regard-
less o the AMI etiology, with evidence or suspi-
cion o peritonitis or bowel ischemia or in arction,
urgent exploratory laparotomy and resection o
necrotic bowel is imperative, typically conducted
according to damage control principles with
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subsequent exploration or reassessment o tenu-
ous bowel. Additionally, major abdominal vessels
and mesenteric per usion can be assessed by direct
vessel palpation.
BIBLIOGRAPHY
Albertson E, Derlet RW, Van Hoozen BE. Methamphetamine
and the expanding complications o amphetamines. West J
Med. 1999;170:2149.
Baker RJ. In: Fischer JE, Jones DB, Pomposeli FB, et al. eds.
Mastery o Surgery. 6th ed. Philadelphia, PA: Wolters Kluwer
Health; 2011:892.
Brannan A, Soundararajan S, Houghton BL. Methamphet-
amine-associated shock with intestinal in arction. Med-
GenMed. 2004;6:6.
Carlson , Plackett, , Gagliano RA, et al. Crystal Meth-
amphetamine-Induced Paralytic Ileus. Hawaii Journal
o Medicine & Public Health. February 2012; 71(2):445.
Chander B, Aslanian HR. Gastric per orations associated with
the use o crack cocaine. Gastroenterol Hepatol (NY). 2010;
6(11):7335.
Chey WD, Wong BCY. American college o gastroenterology
guideline on the management o helicobacter pylori in ec-
tion. Am J Gastroenterol. 2007;102(8):180825.
Dunser MW, Hasibeder WR. Sympathetic overstimulation
during critical illness: Adverse e ects o adrenergic stress.
J Intensive Care Med. 2009;24:293316.
Feliciano DV, Ojukwu JC, Rozycki GS, et al. T e epidemic o
cocaine-related juxtapyloric per orations: with a comment
on the importance o testing or Helicobacter pylori. Ann
Surg. 1999;229:8014.
Grassi R, Romano S, Pinto A, et al. Gastroduodenal per o-
rations: conventional plain ilm, US and C indings in
166 consecutive patients. Eur J Radiol. 2004;50(1):306.
Herr RD, Caravati EM. Acute transient ischemic colitis a er
oral methamphetamine ingestion. Am J Emerg Med. 1991;
9:4069.
Herskowitz MM, Gilego V, Ward M, et al. Cocaine-induced
mesenteric ischemia: reatment with intra-arterial papav-
erine. Emerg Radiol. 2002;9(3):1724.
Kish SJ. Pharmacologic mechanism o crystal meth. CMAJ.
2008;178:167982.
Mulholland MW. In: Mulhollond MW, Lillemoe KD, Goherty
GM, et al. eds. Greenf elds Surgery: Scientif c Principles and
Practice. 5th ed. Philadelphia, PA: Lippincott Williams &
Wilkins; 2010: Ch44, pp 699703.
Nirula R. Gastroduodenal Per oration. Surg Clin North Am.
2014;94(1):314.
Ng EK, Lam YH, Sung JJ, et al. Eradication o Helicobacter
pylori prevents recurrence o ulcer a er simple closure o
duodenal ulcer per oration: Randomized controlled trial.
Ann Surg. 2000;231(2):1538.
Nirula R. Acute Mesenteric Ischemia. Surg Clin North Am.
2014;94(1):16581.
Osorio J1, Farreras N, Ortiz DeZrate L, et al. Cocaine-induced
mesenteric ischaemia. Dig Surg. 2000;17(6):64851.
 C H AP TER 4 5 I l l I C I T D Ru g - In D u C ED Ab D o m I n Al PAI n 159

Pecha RE, Prindiville , Pecha BS, et al. Association o cocaine
and methamphetamine use with giant gastroduodenal
ulcers. Am J Gastroenterol. 1996;91:252327.
Reginelli A, Iacobellis F, Berritto D, et al. Mesenteric ischemia:
the importance o di erential diagnosis or the surgeon.
BMC Surg. 2013;13(Suppl 2):S51.
Shanti CM, Lucas CE. Cocaine and the critical care challenge.
Crit Care Med. 2003;31(6):18519.
rompeter M, Brazda , Remy C , et al. Non-occlusive mes-
enteric ischemia: Etiology, diagnosis, and interventional
therapy. Eur Radiol. 2002;12(5):117987.

http://surgerybook.net/
 46
Carcinoid umors

Christopher Yheulon

A 50-year-old otherwise healthy male presents to the 1. What is the best next step in diagnosis?
emergency room with nausea, vomiting, and abdomi- A. Small bowel ollow through
nal pain. He has had a one month history o chronic B. Abdominal MRI
intermittent abdominal pain. He has no prior history o C. Capsule Endoscopy
abdominal surgeries and had a normal colonoscopy ear- D. Barium Enema
lier this year. His vital signs are within normal limits. On E. Diagnostic Laparoscopy
exam, his abdomen is so , non-distended, with mild di -
use abdominal tenderness. T ere are no hernias present. 2. What is the most likely malignant pathologic
His laboratory exam is unremarkable. He undergoes diagnosis?
an abdominal C scan which demonstrates an area o A. Adenocarcinoma
intussusception in the distal small bowel with thickening B. Carcinoid tumor
and calci cation o the adjacent mesentery (seen below). C. Lymphoma

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 C H AP TER 4 6 C ARC i n o i d Tu m o Rs 161

D. Small bowel sarcoma additional in ormation, surgery remains the de ni-

E. Small bowel gastrointestinal stromal tumor tive modality or diagnosis and treatment o adult
(GIS ) intussusceptions.
T is di ers rom intussusception in a child which
3. A er you complete your diagnostic workup, is typically idiopathic or associated with a viral
you take the patient to the operating room or a in ection. Non-operative enema reduction is the
diagnostic laparoscopy. You identi y a 4 cm solid treatment o choice o uncomplicated intussuscep-
mass in the mid-jejunum. T e adjacent mesentery tion in children and has a success rate o 90%. Sur-
appears thickened and ore-shortened. T ere is gery is reserved or children with evidence o shock,
no evidence o metastatic disease. You per orm peritonitis, or ailed enema reduction.
a resection with primary anastamosis. In the
recovery room, the patient has pro ound f ushing, 2. B. T e most common small bowel malignancy is
altered mental status, and hypotension re ractory carcinoid tumor (37.4%), ollowed by adenocar-
to f uid resuscitation. What is the next best step in cinoma (36.9%), lymphoma (17.3%), and stromal
management? tumor (8.4%). T e most requent location o carci-
A. Initiation o vasopressors noid tumors are the ileum, ollowed by the duode-
B. Broad spectrum antibiotics num, and least requently in the jejunum.
C. IV octreotide 3. C. his patient has developed carcinoid crisis.
D. Stress dose corticosteroids Carcinoid crisis is a phenomenon that occurs a ter
E. rans usion o packed red blood cells (PRBCs) manipulation o tumor masses, during induction
4. T e patient ultimately recovers well and is o anesthesia, and a ter administration o chemo-
discharged. What labs should be ordered or therapy, but can also occur in up to 11% o patients
surveillance o recurrence and metastatic disease? with metastatic disease. Signi icant amounts o
serotonin, histamine, and other mediators cause
A. Chromogranin A and Urine 5-HIAA the characteristics o pro ound lushing, extreme
B. CEA and CA 19-9 changes in blood pressure, bronchoconstriction,
C. Plasma VMA and metanephrines arrhythmias, and mental status changes. I the
D. FSH and LH condition is associated with hypotension, it is usu-
E. AFP and HCG ally re ractory to luid resuscitation but can be
5. T ree years later on surveillance C scan, the treated with the in usion o plasma and the use o
patient is noted to have multiple new liver masses. octreotide.
Biopsy is consistent with metastatic disease. What I the diagnosis o carcinoid is made pre-
is the best treatment option? operatively, steps can be taken to reduce the risk o
carcinoid crisis, including administration o anti-
A. Systemic chemotherapy histamines and octreotide. Octreotide is a long act-
B. Metastatectomy ing somatostatin analogue. In addition to reducing
C. Hepatic artery embolization the release o GI hormones, it reduces the amount
D. External beam radiation o serotonin released rom tumor cells. Regardless,
E. Observation intraoperative carcinoid events are dif cult to pre-
dict and there is no standard octreotide administra-
ANSWERS tion regimen available.
1. E. Intussusception in an adult is typically due to a 4. A. Chromogranin A is a protein associated with
pathologic lead point. Only 8% to 20% o intussus- neuroendocrine cells and tumors. It is use ul or
ceptions are idiopathic. Malignancy accounts or monitoring disease response and progression in
up to 30% o cases o adult intussusception. Benign patients with carcinoid tumors. Plasma Chromogra-
causes or intussusception include Meckels divertic- nin A levels are an independent predictor o survival.
ulum, postoperative adhesions, lipomas, adenoma- 5-HIAA is the primary urinary metabolite o seroto-
tous polyps, and intestinal tubes (i.e., jejunostomy). nin. Measuring these levels are use ul or diagnosis,
Although advanced imaging techniques may provide monitoring, and prognosis o patients with carcinoid

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162 G En ERAL s u RG ERY EXAm i n ATi o n An d Bo ARd REVi EW
tumors. T ere is also reduced survival among
patients with elevated Urine 5-HIAA levels and the
degree o elevation is correlated with the degree o
carcinoid symptoms.
CEA is a marker or colon and pancreatic cancer.
CA 19-9 is a marker or pancreatic cancer. Plasma
VMA and metanephrines are use ul in the diagnosis
o pheochromocytoma. FSH and LH are hormones
released by the pituitary gland that are not particu-
larly use ul in tumor surveillance. AFP and b-HCG
can be used to identi y testicular cancer.
5. B. Many di erent chemotherapy regimens or car-
cinoid tumors have been investigated with response
rates ranging only rom 0% to 33%. Chemotherapy
has not been shown to improve survival but is typi-
cally used or control o symptoms caused by metas-
tases.
Surgery or metastatic carcinoid disease has
been shown to relieve symptoms related to intes-
tinal obstruction and ischemia. Multiple studies
have shown that surgery provides an improved con-
trol o carcinoid syndrome symptoms. In addition,
cytoreductive surgery to include liver metastases has
shown to improve survival when compared to obser-
vation, systemic chemotherapy, and hepatic artery
embolization.
In 2006, Osborne et al. demonstrated that patients
who underwent cytoreductive resection or meta-
static carcinoid tumor had better complete symptom
relie (69% vs. 59%) and a signi cantly longer mean
http://surgerybook.net/
survival (43 vs. 24 months) when compared to those
patients undergoing embolization.
BIBLIOGRAPHY
Bilimoria KY, Bentrem DJ, Wayne JD, et al. Small bowel cancer
in the United States: Changes in epidemiology, treatment,
and survival over the last 20 years. Ann Surge. 2009;249(1):
6371.
Chambers AJ, Pasieka JL, Dixon E, Rorstad O. T e palliative
bene t o aggressive surgical intervention or both hepatic
and mesenteric metastases rom neuroendocrine tumors.
Surgery. 2008;144(4):64551.
Kulke MH. Clinical presentation and management o car-
cinoid tumors. Hematol Oncol Clin North Am. 2007;21:
43355.
Mancuso K, Kaye AD, Boudreaux JP, et al. Carcinoid syn-
drome and perioperative anesthetic considerations. J Clin
Anesth. 2011;23(4):32941.
Marinis A, Yiallourou A, Samanides L, et al. Intussusception o
the bowel in adults: A review. World J Gastroenterol. 2009;
15(4):40711.
Modlin IM, Kidd M, Latich I, et al. Current status o gastro-
intestinal carcinoids. Gastroenterology. 2005;128:171751.
Musunuru S, Chen H, Rajpal S, et al. Metastatic neuroendo-
crine hepatic tumors: Resection improves survival. Arch
Surg. 2006;141(10):10004.
Osborne DA, Zervos EE, Strosberg J, et al. Improved outcome
with cytoreduction versus embolization or symptom-
atic hepatic metastases o carcinoid and neuroendocrine
tumors. Ann Surg Oncol. 2006;13(4):57281.
Rorstad O. Prognostic indicators or carcinoid neuroendo-
crine tumors o the gastrointestinal tract. J Surg Oncol.
2005;89(3):15160.
Vaughan DJ, Brunner MD. Anesthesia or patients with car-
cinoid syndrome. Int Anesthesiol Clin. 1997;35(4):12942.
 47
Mesenteric Ischemia

Danielle E. Ca asso

A 67-year-old male with a history o hypertension, C. Supportive care with avoidance o vasopressors
atrial brillation, and obesity presents to the emer- and optimization o uid status
gency department with acute onset abdominal pain, D. Mesenteric bypass
nausea, vomiting, and hematochezia. Previous opera- E. Surgical embolectomy
tions include a laparoscopic appendectomy. On physical
exam the patient appears to be in signi cant distress due 4. During surgical exploration, the bowel is assessed
to pain; however, his abdomen is so , non-tender, and or viability and 50 cm o small bowel is resected.
non-distended. Laboratory analysis is remarkable or a What is the most reliable means o determining
white blood cell count o 21 109/mL and a lactate o bowel viability af er revascularization?
3.5 mmol/L. Abdominal radiography is unremarkable. A. Second-look laparotomy
C angiography is signi cant or absence o ow distal B. Acid-base status
to the origin o the superior mesenteric artery (SMA). C. Intraoperative Doppler ultrasound
D. ranscutaneous oxygen measurement
1. What is the likely etiology or this SMA occlusion?
E. Resection o all necrotic and marginal appearing
A. Splanchnic vasoconstriction bowel during initial exploration
B. Embolic occlusion o the mesenteric circulation
C. Acute thrombosis o the mesenteric circulation 5. Regarding outcomes, which o the ollowing is
D. Hypercoagulable state true?
E. Mesenteric venous thrombosis (MV )
A. Delays in diagnosis contribute to the high
2. Associated risk actors with acute mesenteric morbidity and mortality in mesenteric isch-
ischemia include which o the ollowing? emia.
A. Hypertension B. Mesenteric ischemia-reper usion is an uncom-
B. Malignancy mon cause or postoperative morbidity.
C. Recent cardiac events C. MV has a worse prognosis than other orms o
D. Hypovolemia mesenteric ischemia.
E. All o the above D. Endovascular intervention is the mainstay o
treatment or all orms o mesenteric ischemia
3. What is the optimal management approach or today.
this patient? E. Percutaneous transluminal angioplasty (P A)
A. T erapeutic anticoagulation or chronic mesenteric ischemia is associated
B. Intra-arterial thrombolytics with a low restenosis rate.

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16 4 G EN ERAL S U RG ERY EXAM I N ATI O N AN D BO ARD REVI EW
ANSWERS
1. B. T ere are our distinct pathophysiologies or mes-
enteric ischemia: arterial thromboembolism, hypop-
er usion syndrome, acute arterial thrombosis on
chronic ischemia, and venous thrombosis. Arterial
types are classi ed as acute or chronic. Acute mes-
enteric ischemia (AMI) is due to either thromboem-
bolism or hypoper usion syndromes, also known as
non-occlusive mesenteric ischemia (NOMI). Acute
on chronic mesenteric ischemia is due to thrombotic
occlusion in the setting o atherosclerotic disease.
Finally, there is one classi cation or venous mesen-
teric ischemia and that is due to MV .
T e most common type is arterial embolism
comprising approximately 50% o cases. T e classic
presentation is acute onset periumbilical abdominal
pain out o proportion to physical exam ndings. A
retrospective study o patients with AMI who under-
went surgery ound the most requent presenting
symptom was abdominal pain (95%), with nausea
(44%), vomiting (35%), and diarrhea (35%) to ol-
low. Patients with thrombotic occlusion, acute-on-
chronic mesenteric ischemia, typically have a history
o chronic postprandial abdominal pain and weight
loss due to ood ear. It is common in the elderly
population with di use atherosclerosis leading to
relative ischemia a er meals.
Patients with mesenteric hypoper usion, or
NOMI, are usually critically ill patients who pre-
sent with a slower onset o di use abdominal pain
related to splanchnic vasoconstriction in a low- ow
state. T ose with MV may have various, nonspe-
ci c abdominal complaints insidious in onset which
progressively worsen over time. It is also worth men-
tioning median arcuate ligament syndrome (MALS),
which is a compressive syndrome o the celiac artery
on expiration. T e presenting symptoms are similar
to other orms o mesenteric ischemia and MALS is
o en associated with recent weight loss. MALS is a
diagnosis o exclusion and management is outside
the scope o this chapter.
Further diagnosis o mesenteric ischemia relies on
associated risk actors, which will be discussed below,
as well as laboratory analysis and imaging. One study
ound the mean white blood cell (WBC) count to be
elevated in 98% o patients, and greater than 20
109/mL in over hal o the patients. Lactate was also
elevated in greater than 90% o patients and greater
than 3 mmol/L in over 60% o patients. Imaging may
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include abdominal X-rays, duplex ultrasonography,
computed tomographic angiography (C A), mag-
netic resonance angiography (MRA), and contrast
angiography. Contrast angiography is considered the
gold standard providing both diagnostic and thera-
peutic options; however, C A and MRA are com-
monly used as well.
Abdominal X-rays may show uid- lled loops o
bowel with bowel wall edema. Endoscopy may be use-
ul or acute on chronic ischemia where the duode-
num and right colon may have evidence o ischemia.
Classic angiographic patterns exist that assist in the
diagnosis o mesenteric ischemia. Firstly, the SMA is
the most common site o embolism due to its high
basal ow rate and anatomic angle o takeo rom
the aorta. Secondly, the emboli typically lodge distal
to the middle colic branch and the jejunal branches.
It appears as an oval-shaped clot surrounded by
contrast in a non-calci ed segment. On the other
hand, the thrombus in acute on chronic mesen-
teric ischemia typically orms at the atherosclerotic
plaque, most commonly at the origin o the mesen-
teric vessel causing complete absence o ow. It will
appear as a clot superimposed on a heavily calci ed
occlusive lesion at the ostium. NOMI is caused by
hypoper usion or a low- ow state, thus angiographic
ndings include the absence o large vessel occlusion
with evidence o sequential ocal vasospasm. Finally,
MV ndings include bowel wall thickening, delayed
passage o contrast into the portal system, and a lack
o opaci cation o the portal vein. It is actually better
diagnosed with C A with portal phase enhancement.
2. E. Associated risk actors or acute mesenteric
ischemia (AMI) are essential to the diagnosis. Gen-
eral risk actors or AMI include hypertension,
tobacco use, peripheral vascular disease, and coro-
nary artery disease. Arterial embolic occlusion is
most commonly associated with a cardiac source
such as atrial brillation leading to atrial append-
age thrombus. Other causes include valvular disease
and le ventricular mural thrombus due to previous
myocardial in arction (MI) and subsequent hypoki-
nesis. Arterial thrombosis involves a slow progression
o atherosclerosis until a critical stenosis and subse-
quent thrombosis develops, thus patients will have
other mani estations o atherosclerotic disease. Low
ow states can result in acute on chronic ischemia
and has been associated with MI, recent cardiac sur-
gery, and acute viral illness. NOMI is also related to

low ow states, but without ocal occlusion. Patients
in cardiogenic or septic shock, those with vasopres-
sor in usions, or patients with toxic pharmacologic
ingestion have all been implicated as inciting events
or NOMI. Dialysis patients with excessive uid
removal are also at risk. In contrast, MV is o en
due to systemic disease related to hypercoagulable
states such as malignancy, trauma, medications, and
hypercoagulable syndromes.
3. E. reatment goals in AMI include restoration o
normal pulsatile ow and resection o nonviable
bowel. Open surgery and endovascular interven-
tion can both restore ow; however, open laparot-
omy may be required to assess bowel viability and
is mandatory with peritonitis unless palliative
management is planned. T e progression o endo-
vascular technology and skill over the last decade
has made an endovascular or hybrid approach
more common and more accepted. Multiple non-
randomized studies have been published but with
con icting reports. One retrospective study o
over 4,000 patients compared outcomes or endo-
vascular vs. open surgery in the treatment o AMI
(Beaulieu RJ, et al.) Endovascular intervention had
a decreased mortality and shorter length o hos-
pital stay when compared to open surgery. Other
studies report decreased morbidity and mortality
or endovascular intervention in acute thrombotic
occlusions while others still report no di erence in
mortality between the groups. However, no rand-
omized clinical trials exist. More importantly, endo-
vascular or a hybrid approach requires a vascular
center with appropriate acilities and support in
place to be success ul.
Surgical embolectomy is the standard treatment
or arterial embolic occlusion. T e occlusion is not
likely amenable to thrombolytic therapy as it is a
relatively organized cardiac thrombus. Furthermore,
thrombolytics risks distal embolization and bowel
in arction. T e standard surgical approach is a trans-
verse arteriotomy with thromboembolectomy using a
3- or 4-Fr Fogarty catheter. In patients without perito-
nitis, endovascular aspiration embolectomy is a treat-
ment option. Further, catheter directed thrombolysis
is an alternative option in cases o incomplete aspira-
tion embolectomy or distal embolization. T rombotic
arterial occlusion can be managed endovascularly
with stenting and/or thrombolytic therapy as this is
a resh thrombus. However, the patient may require
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C H AP TER 4 7 M ES EN TERIC I S C H EM I A 16 5
exploratory laparotomy i bowel ischemia is a concern.
Revascularization usually precedes bowel resection
and treatment o the underlying stenosis or occlusive
lesion is typically done during the same procedure.
Open surgical management involves surgical
bypass o the occlusion, and may be necessary in
unsuccess ul embolectomy as well. Retrograde
bypass rom the in rarenal aorta or iliac artery is
pre erred due to easier exposure and less hemody-
namic changes as it avoids supraceliac cross-clamp.
However, retrograde bypass may produce in erior
results. Antegrade bypass rom the suprarenal aorta
is less susceptible to kinking, however may be more
di cult due to post-surgical adhesive disease and
calci c atherosclerotic disease. A hybrid approach
with SMA thrombectomy ollowed by retrograde
stenting o the lesion is also an option.
NOMI is pre erably managed non-operatively
with optimization o uid status and cardiac out-
put, and limitation o vasoconstrictors. Interest-
ingly, one study ound that 40% o patients with
NOMI had a potentially treatable SMA stenotic
lesion, thus angiography should be per ormed i at
all possible. Other potential causes o NOMI that
should be addressed include aortic dissection or
abdominal compartment syndrome (ACS) which
is commonly seen a er ruptured abdominal aor-
tic aneurysm (AAA) repair. T e mainstay o MV
treatment is therapeutic systemic anticoagulation
and urther workup to identi y the underlying
cause. For the ew patients that ail medical man-
agement, endovascular options do exist but there
are no studies with comparative data. In all cases,
clinical deterioration with peritonitis or any con-
cern or bowel ischemia requires surgical explora-
tion to assess bowel viability.
4. A. Regardless o surgical approach or methods to
assess bowel per usion at initial exploration, a second-
look laparotomy is essential in the management o
AMI. Published criteria or a second-look lapa-
rotomy include low ow state, bowel resection, and
mesenteric thromboembolectomy. T e key is to
plan the return to the operating room 2448 hours
a er initial exploration no matter what the patients
condition. A er resuscitation and correction o
acid-base imbalances, patients conditions may
improve drastically; however, there is still the risk or
necrotic bowel requiring resection. Clearly necrotic
bowel must be resected at the initial operation,
16 6 G EN ERAL S U RG ERY EXAM IN ATI O N AN D BO ARD REVIEW
however marginally per used bowel needs urther
evaluation to limit the risk o excessive bowel resec-
tion and potentially short gut syndrome. Pulse exam,
intraoperative Doppler ultrasound, uorescein, and
transcutaneous oxygen measurements are all intra-
operative diagnostic options to assess bowel viability
a er revascularization, but second-look laparotomy
is the most reliable means o determining the via-
bility o marginally per used bowel a er revascula-
rization.
5. A. As previously discussed, endovascular therapies
are an option but not currently considered stand-
ard o care due to the lack o randomized controlled
trials and evidence-based outcomes indicating the
superiority o endovascular intervention. P A with
or without stent placement is a therapeutic option
or chronic mesenteric ischemia, however the long-
term risk or restenosis remains relatively high. T ere
are no large, randomized, controlled trials compar-
ing P A with or without stenting and open surgical
revascularization. T us, close surveillance or recur-
rence o stenosis is mandatory.
Mesenteric ischemia has a poor prognosis with
mortality rates reported at 30% or embolic and
thrombotic ischemia, and 80% or NOMI. Diagnos-
tic delays may be the most important prognostic
actor, but comorbidities may place patients at ur-
ther cardiac risk and postoperative complications.
A signi cant proportion o morbidity and mortal-
ity is due to the subsequent development o multi-
organ dys unction syndrome (MODS) in relation
to mesenteric ischemia and reper usion. Intestinal
reper usion injury leads to synthesis and release o
in ammatory mediators, the ormation o reactive
oxygen species, and cell membrane instability which
ultimately causes remote organ injury. Overall MV
does have a better prognosis than other orms o
mesenteric ischemia; however, long-term prognosis
or MV is based on the underlying pathology. T us
malignancy is associated with shorter survival.
BIBLIOGRAPHY
Acosta S, Bjorck M. Modern treatment o acute mesenteric
ischaemia. Br J Surg. 2014;101(1):e1008.
Acosta S, Ogren M, Sternby NH, Bergqvist D, Bjorck M. Fatal
nonocclusive mesenteric ischaemia: Population-based
incidence and risk actors. J Intern Med. 2006;259(3):
30513.
Acosta S, Alhadad A, Ekberg O. Findings in multi-detector
row C with portal phase enhancement in patients with
http://surgerybook.net/
mesenteric venous thrombosis. Emerg Radiol. 2009;
16(6):47782.
Arthurs ZM, itus J, Bannazadeh M, et al. A comparison o
endovascular revascularization with traditional therapy
or the treatment o acute mesenteric ischemia. J Vasc Surg.
2011;53(3):698704; discussion 7045.
Atkins MD, Kwolek CJ, LaMuraglia GM, Brewster DC, Chung
K, Cambria RP. Surgical revascularization versus endo-
vascular therapy or chronic mesenteric ischemia: A com-
parative experience. J Vasc Surg. 2007;45(6):116271.
Beaulieu RJ, Arnaoutakis KD, Abularrage CJ, E ron D ,
Schneider E, Black JH, 3rd. Comparison o open and endo-
vascular treatment o acute mesenteric ischemia. J Vasc
Surg. 2014;59(1):15964.
Belkin M, Owens C, Whittemore A, Donaldson M, Conte
M, Gravereaux E. Mesenteric ischemia. In: ownsend C,
Beauchamp R, Evers B, Mattox K, eds. Sabiston textbook
of surgery. 18th ed. Philadelphia, PA: Saunders Elsevier;
2008.
Bobadilla JL. Mesenteric ischemia. Surg Clin North Am. 2013;
93(4): 92540, ix.
Harnik IG, Brandt LJ. Mesenteric venous thrombosis. Vasc
Med. 2010;15(5):40718.
Kasirajan K, OHara PJ, Gray BH, et al. Chronic mesenteric
ischemia: Open surgery versus percutaneous angioplasty
and stenting. J Vasc Surg. 2001;33(1):6371.
Kibbe M, Hassoun H. Acute mesenteric ischemia. ACS Surgery:
Principles and Practice, 6th edition, 2014;10161026.
Lee H, Ko EH, Lai M, et al. Delineating the relationships
among the ormation o reactive oxygen species, cell mem-
brane instability and innate autoimmunity in intestinal
reper usion injury. Mol Immunol. 2014;58(2):15119.
Moore EE, Moore FA, Franciose RJ, Kim FJ, Bif WL, Banerjee
A. T e postischemic gut serves as a priming bed or cir-
culating neutrophils that provoke multiple organ ailure.
J Trauma. 1994;37(6):8817.
Paladino NC, Inviati A, Di Paola V, et al. Predictive actors
o mortality in patients with acute mesenteric ischemia.
A retrospective study. Ann Ital Chir. 2014 May-Jun; 85(3):
26570.
Park WM, Gloviczki P, Cherry KJ, Jr, et al. Contemporary
management o acute mesenteric ischemia: Factors associ-
ated with survival. J Vasc Surg. 2002;35(3):44552.
Rose SC, Quigley M, Raker EJ. Revascularization or chronic
mesenteric ischemia: Comparison o operative arterial
bypass gra ing and percutaneous transluminal angio-
plasty. J Vasc Interv Radiol. 1995;6(3):33949.
Ryer EJ, Kalra M, Oderich GS, et al. Revascularization
or acute mesenteric ischemia. J Vasc Surg. 2012;55(6):
16829.
Sise MJ. Acute mesenteric ischemia. Surg Clin North Am.
2014;94(1):16581.
allarita , Oderich GS, Macedo A, et al. Reinterventions
or stent restenosis in patients treated or atheroscle-
rotic mesenteric artery disease. J Vasc Surg. 2011;54(5):
14229.e1.
Yanar H, aviloglu K, Retaken C, et al. Planned second-look
laparoscopy in the management o acute mesenteric isch-
emia. World J Gastroenterol. 2007;13(24):33503.
 48
Appendicitis
Erik Criman
You are called to the emergency department to evaluate
a 25-year-old woman complaining o abdominal pain
starting 12 hours prior to presentation. She initially
characterized the pain as a periumbilical discom ort, but
now it is sharp and localizes to her right lower quadrant.
Review o systems is positive or a temperature eleva-
tion (measured at 38C at home), anorexia, and nausea
without emesis, and the patient denies diarrhea, melena,
and hematochezia. Her past medical history, past surgi-
cal history, social history, and amily history are all unre-
markable. T e patients last menstrual period was three
weeks ago. She does not take any scheduled medications
and has no known allergies. Measurement o her vital
signs demonstrate a temperature o 37.8C, heart rate o
88 beats per minute, blood pressure o 118/74 mm Hg,
respiratory rate o 18 breaths per minute, and oxygen
saturation o 98% on room air. Physical examination is
normal except or ocal tenderness to palpation most
prominent at McBurneys point.
1. What is the most important laboratory test to
order for this patient?
A. Complete blood count
B. ype and screen
C. Prothrombin time (P ) and partial thrombo-
plastin time (P )
D. Human chorionic gonadotropin
E. Complete metabolic panel
2. Regarding the clinical manifestations of this
diagnosis, which of the following is correct?
A. T e location o the appendiceal tip has little to
do with determining the presenting symptoms.
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B. Only 25% o adult patients with acute appendici-
tis will present with a classic history.
C. A clinical diagnosis o acute appendicitis is more
accurate in men than women.
D. T e appendiceal obstruction is not the hypoth-
esized pathogenesis o acute appendicitis.
E. Delay in diagnosis and/or surgical interven-
tion is the most common cause o complicated
(gangrenous or per orated) appendicitis rather
than patient delay in seeking medical atten-
tion.
3. Regarding the use of imaging in acute appendicitis,
which of the following is correct?
A. Ultrasound is the most speci c imaging study
available.
B. Selective imaging has been used to lower the
accepted negative appendectomy rate to less
than 20%.
C. Con rmatory imaging is not required to make
the diagnosis o acute appendicitis in all cases
prior to de nitive management.
D. T e most accurate ultrasound nding in acute
appendicitis is the presence o mesenteric
lymphadenopathy.
E. For pregnant women, magnetic resonance imag-
ing (MRI) is not recommended when ultrasound
is non-diagnostic.
4. Regarding non-operative management of acute
appendicitis, which of the following is correct?
A. Non-operative management has been de ni-
tively shown to be cost e ective.
16 8 G EN ERAL S U RG ERY EXAM I N ATI O N AN D BO ARD REVI EW
B. Surgical management is the standard o care or
acute appendicitis in the United States.
C. No trials have demonstrated a potential bene t
to medical management.
D. Non-operative management has consistently
been shown to reduce length o stay.
E. T e presence o a ecalith on imaging does not
predispose a patient to ail non-operative man-
agement.
5. A decision is made to take the patient to the
operating room for a laparoscopic appendectomy.
Regarding possibilities that may occur during the
operation, which of the following is correct?
A. I the appendix appears normal, a diagnostic
laparoscopy should be per ormed to look or
other potential causes o the patients right lower
quadrant pain. T e appendix should NO be
removed in such cases.
B. I a sub-centimeter mass is identi ed at the
appendiceal tip, one should per orm an ileo-
cecectomy.
C. I an enterotomy occurs during trocar place-
ment, one should per orm a bowel resection and
not attempt primary repair.
D. I a ree rupture o the appendix with ecal con-
tamination o the peritoneal cavity has occurred,
one should do a washout only at this operation
and manage the patient post-operatively with
antibiotics.
E. I one encounters a per orated appendix, leaving
a drain has not been shown to reduce the rate o
abscess ormation.
ANSWERS
Introduction to Acute Appendicitis.
Acute in ammation o the vermi orm appendix,
rst described by Fitz in 1886, is one o the most com-
mon causes o the acute abdomen encountered by the
general surgeon. Anatomically, this structure is a true
diverticulum o the cecum as it contains all layers o
the colonic wall. It receives its arterial supply rom the
appendiceal artery (a terminal branch o the ileocolic
artery). It is invariably ound at the base o the cecum
at the convergence o the taenia coli. T is structure is
histologically distinct rom the cecum in that it contains
lymphoid tissue in the mucosa and submucosa. Epide-
miologically, acute appendicitis presents most com-
monly in the second generation o li e, is 1.4 times more
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common in men, is 1.5 times more common in whites,
and is 11.3% more common in the summer months.
T e estimated li etime risk o acute appendicitis is
8.6% or males and 6.7% or emales. T e hypothesized
pathogenesis o acute appendicitis is that o appendi-
ceal obstruction. T is may be caused by a ecalith, true
calculi, lymphoid hyperplasia, masses (both benign and
malignant), or in ectious processes. When the appendix
becomes obstructed, increased intraluminal pressure
causes localized ischemia leading eventually to per o-
ration and localized abscess ormation or generalized
peritonitis.
1. D. All women o childbearing age must have a preg-
nancy test or two reasons. First, it narrows the di er-
ential diagnosis. T e di erential diagnosis or acute
right lower quadrant pain is extensive, especially in
a emale o childbearing age. It includes such enti-
ties as in ammatory bowel disease (Crohns Disease,
Ulcerative Colitis), ileitis, epiploic appendagitis, cecal
diverticulitis, Meckels diverticulitis, and renal colic.
Speci c to women, obstetrical diagnoses (pregnancy,
ectopic pregnancy) and gynecologic diagnoses (rup-
tured ovarian cyst, endometriosis, pelvic in amma-
tory disease, tubo-ovarial abscess, Mittelschmerz,
ovarian torsion) are in play. A rectal examination
along with pelvic examination in women or geni-
tourinary examination in men should be consid-
ered. Second, the result o this test will most directly
impact the diagnostic workup and management o
the patient. I the patient is ound to be pregnant
and is still suspected to have acute appendicitis, the
diagnostic study o choice will change (ultrasound
vs. MRI over computerized tomography (C )), tera-
togenic medications should be avoided, and etal
heart tones will be documented both be ore and a er
anesthesia.
2. C. Clinical diagnosis o acute appendicitis is more
accurate in men than it is in women. While the over-
all accuracy o a clinical diagnosis o acute appen-
dicitis is given as approximately 80%, this value is
signi cantly higher in men than women because
acute obstetric and gynecologic pathology may
con ound the diagnosis. T e anatomic location o
the appendix along with the time o the presenta-
tion determines the clinical mani estations o acute
appendicitis. Further, the classic presentation o
appendicitis (vague peri-umbilical discom ort ol-
lowed by nausea and anorexia ollowed by migration

o the pain to the right lower quadrant) only occurs
in 50% to 60% o presentations. Interestingly, patient
delay in seeking medical attention is cited as the
most common cause or the intra-operative ndings
o gangrenous or per orated appendicitis. T e other
actor that heavily in uences delay in diagnosis is
the patients age. Appendicitis o en presents atypi-
cally in children (particularly those younger than
three years o age) and the elderly (de ned as those
patients over sixty). Adult patients who are obese,
diabetic, or immunologically compromised may
also present in an atypical manner. A high index o
suspicion is required to make the diagnosis in these
patient populations.
3. C. Con rmatory imaging is not required to diag-
nose acute appendicitis, and there is evidence to
suggest that waiting or imaging only serves to delay
de nitive management in cases where there is little
doubt o the history, physical exam, and laboratory
evaluation. While historically the negative appen-
dectomy rate was accepted as 10% or men and 20%
or women, this value has been reduced to less than
10% with the selective use o pre-operative imag-
ing (primarily C ) in cases where the diagnosis is
not clinically apparent. Computerized tomography
is the most speci c imaging modality available,
with an estimated speci city o above 95%. Regard-
ing ultrasound, an appendiceal diameter o 6 mm
or greater has been set as the threshold or making
the diagnosis o acute appendicitis in an individual
with coexistent right lower quadrant pain. MRI is
recommended or pregnant women when the trans-
abdominal ultrasound is non-diagnostic or acute
appendicitis.
4. B. Surgical management remains the standard
o care or acute appendicitis in the United States.
Appendectomy, increasingly done using a laparo-
scopic approach, has become an extremely sa e pro-
cedure with a reported intra-operative complication
rate o 0.7% and general post-operative complication
rate o 1.5%. In the adult literature, there has recently
been some promising research including several
randomized, prospective trials that collectively have
documented an aggregate treatment ailure rate and
recurrence rate (adjudged as crossing over to opera-
tive management) ranging rom 14% to 32% at 2 years.
For those who are success ully managed non-
operatively, reviews have demonstrated decreased
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C H AP TER 4 8 AP P EN D I C I TI S 16 9
morbidity, decreased pain, and a reduced amount
o sick leave and disability. Un ortunately, there has
also been evidence that those who ail conservative
management more o en present with abscess or per-
oration (around 30%). Non-operative management
has also not been shown to be cost e ective because
o an associated longer length o stay along with the
cost o re-admission and cross-over to the operative
arm. T e presence o a ecalith is considered a con-
traindication to non-operative management because
this nding has an association with treatment ailure,
recurrence, and complicated appendicitis.
5. E. T ere is no evidence that drains reduce complica-
tions (e.g., abscess ormation, wound in ection) ol-
lowing appendectomy or any stage o appendicitis.
In the event that a normal appearing appendix is
encountered intra-operatively, care should be taken
to per orm a thorough evaluation o the peritoneal
cavity. Most authors recommend incidental appen-
dectomy to remove appendicitis rom the di eren-
tial going orward. It should be noted that even i the
appendix appears normal, nal pathology will not
in requently demonstrate in ammation consistent
with a diagnosis o acute appendicitis. Appendiceal
tumors are rare and are only ound in 1% o appen-
dectomy specimens. O these, carcinoid tumors are
the most common (> 50%) and 90% are located at
the appendiceal tip. I the tumor is less than 2 cm,
an appendectomy is adequate. I the tumor is greater
than 2 cm in size or there is a question o incom-
plete resection (positive margins, grossly positive
lymph nodes), the National Comprehensive Cancer
Network (NCCN) recommendation is initial appen-
dectomy ollowed by re-exploration and right partial
colectomy i the staging evaluation is negative or
metastatic disease.
An enterotomy may be repaired primarily i it is
identi ed at the time o the original operation. While
operative management o appendiceal phlegmon or
abscess at the time o presentation is controversial,
thorough washout and appendectomy (either lapa-
roscopically or via laparotomy) without drain place-
ment is indicated or cases o ecal peritonitis caused
by ree rupture o the appendix.
BIBLIOGRAPHY
Addiss DG, Sha er N, Fowler BS, auxe RV. T e epidemiology
o appendicitis and appendectomy in the United States.
Am J Epidemiol. 1990;132(5):910.
170 G EN ERAL S U RG ERY EXAM I N ATI O N AN D BO ARD REVIEW
Binenbaum SJ, Gold arb MA. Inadvertent enterotomy in
minimally invasive abdominal surgery. JSLS. 2006;10(3):
33640.
Birnbaum BA, Wilson SR. Appendicitis at the millennium.
Radiology. 2000;215(2):337348.
Brgger L, Rosella L, Candinas D, Gller U. Improving out-
comes a er laparoscopic appendectomy: A population-
based, 12-year trend analysis o 7446 patients. Ann Surg.
2011;253(2):309.
Chiarugi M, Buccianti P, Decanini L, Balestri R, Lorenzetti L,
Franceschi M, Cavina E. What you see is not what you get.
A plea to remove a normal appendix during diagnostic
laparoscopy. Acta Chir Belg. 2001;101(5):243.
Connor SJ, Hanna GB, Frizelle FA. Appendiceal tumors: Ret-
rospective clinicopathologic analysis o appendiceal tumors
rom 7970 appendectomies. Dis Colon Rectum. 1998;41(1):75.
Daehlin L. Acute appendicitis during the rst three years o
li e. Acta Chir Scand. 1982;148(3):291.
Di Saverio S, Sibilio A, Giorgini E, Biscardi A, Villani S,
Coccolini F, et al. T e NO A Study (Non-Operative reat-
ment or Acute Appendicitis): Prospective study on the
ef cacy and sa ety o antibiotics (Amoxicillin and Clavu-
lanic Acid) or treating patients with right lower quadrant
abdominal pain and long-term ollow-up o conservatively
treated suspected appendicitis. Ann Surg. Jul 18, 2014.
Fitz, RH. Per orating in ammation o the vermi orm appen-
dix with special re erence to its early diagnosis and treat-
ment. Am J Med Sci. 1886;92:321.
Horattas MC, Guyton DP, Wu D. A reappraisal o appendi-
citis in the elderly. Am J Surg. 1990;160(3):291.
Je rey RB Jr, Laing FC, ownsend RR. Acute appendicitis:
sonographic criteria based on 250 cases. Radiology. 1988;
167(2):327.
Lee SL, Walsh AJ, Ho HS. Computed tomography and ultraso-
nography do not improve and may delay the diagnosis and
treatment o acute appendicitis. Arch Surg. 2001;136(5): 556.
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McCutcheon BA, Chang DC, Marcus LP, Inui , Noorbakhsh
A, Schallhorn C, et al. Long-term outcomes o patients
with non-surgically managed uncomplicated appendicitis.
JACS. 2014; 218:905.
National Comprehensive Cancer Network. Neuroendo-
crine umors (Version 2.2014). http://www.nccn.org/
pro essionals/physician_gls/pd /neuroendocrine.pd .
Accessed April 30, 2014.
Parks NA, Schroeppel J. Update on imaging or acute appen-
dicitis. Surg Clin North Am. 2011;91(1):14154.
Park JS, Jeong JH, Lee JI, Lee JH, Park JK, Moon HJ. Accura-
cies o diagnostic methods or acute appendicitis. Am Surg.
January 2013;79(1):1016.
Petrowsky H, Demartines N, Rousson V, Clavien PA.
Evidence-based value o prophylactic drainage in gastro-
intestinal surgery: A systematic review and meta-analyses.
Ann Surg. 2004;240(6):1074.
Pittman-Waller VA, Myers JG, Stewart RM, Dent DL, Page CP,
Gray GA, et al. Appendicitis: Why so complicated? Analy-
sis o 5755 consecutive appendectomies. Am Surg. 2000;
66(6):548.
Shindoh J, et al. Predictive actors or negative outcomes in
initial non-operative management o suspected appendici-
tis. J Gastrointest Surg. 2010;14(2):30914.
Varadhan KK, Neal KR, Lobo DN, et al. Sa ety and ef cacy o
antibiotics compared with appendectomy or treatment o
uncomplicated, acute appendicitis: Meta-analysis o ran-
domized controlled trials. BMJ. 2012;344:e2156
Wagner PL, Eachempati SR, Soe K, Pieracci FM, Shou J, Barie
PS. De ning the current negative appendectomy rate: or
whom is preoperative computed tomography making an
impact? Surgery. 2008;144(2):276.
Wilms I, de Hoog D, de Visser D, Janzing H. Appendec-
tomy versus Antibiotic reatment or Acute Appendi-
citis. Cochrane Review of Systematic Reviews. 2011. doi:
10.1002/14651858.CD008359.pub2.
 49
Colon Cancer
Robert B. Lim
A 48-year-old male is re erred to your o ce or pain-
less hematochezia, which has been present or 1 year. He
notes some mild atigue but is otherwise asymptomatic
and has no other past medical or surgical history. He is
adopted so his amily history is unknown. On physical
exam, he has a BMI o 32 kg/m 2. His rectal and ano-
scopic exam show no lesions. His ecal occult blood test
is positive. T e rest o his exam is normal.
1. T e patient is in the process o nding his biological
amily and is inquiring about risk actors or colon
cancer. Which o the ollowing is true?
A. All newly diagnosed colorectal cancers under
age 70 should be evaluated or the mismatch
repair de ciency o Lynch syndrome.
B. In amilies with suspected amilial adenomatous
polyposis (FAP) syndrome, screening should
start in the third decade o li e and done every
5 years.
C. In patients at risk or attenuated FAP (AFAP), the
average age o onset o colon cancer is the same
as with FAP.
D. In patients with Peutz-Jeghers syndrome, COX-2
inhibitors have been shown to slow the progres-
sion to cancer.
E. In serrated polyposis syndrome, the polyps are
typically hyperplastic in nature and thus, this
syndrome is not associated with an increase risk
o malignancy development.
2. For this patient, the next step in management
should be
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A. Computed tomography (C ) virtual colono-
graphy
B. Fecal immunochemical test
C. Colonoscopy
D. Stool DNA
E. Capsule endoscopy
3. T e entire colon was able to be evaluated and a
4 cm sessile polyp is noted in the distal descending
colon on the above study. A subsequent biopsy is
done which shows a moderately di erentiated
adenocarcinoma with extension past the lamina
propria. T ere are no other lesions in the colon.
Which o the ollowing is the next best step in
management?
A. Le colectomy
B. Repeat colonoscopy to determine i the lesion is
amenable to endoscopic resection.
C. Rigid proctoscopy
D. C scan
E. C /PE scan
4. T e patient is prepared or surgery. He is interested
in a laparoscopic resection so he can return to work
aster. Which o the ollowing is true regarding
laparoscopic approaches?
A. T e robotic assisted laparoscopic approach has
the least amount o blood loss.
B. A single-incision laparoscopic approach has less
pain than other laparoscopic approaches.
C. T e laparoscopic approach has higher rates o
port site/wound recurrences versus an open
approach.
17 2 G EN ERAL S U RG ERY EXAM IN ATIO N AN D BO ARD REVI EW
D. T e laparoscopic approach has less deep surgical
site in ections than does an open approach.
E. A single-incision laparoscopic approach has a
shorter length o hospital stay.
5. A review o your hospitals National Surgical Quality
Improvement Program (NSQIP) data shows that the
average length o stay or colon resections is 9 days.
T e Chie o Surgery is considering implementing
an Enhanced Recovery Af er Surgery (ERAS)
protocol or colon surgery. Which o the ollowing
is true?
A. Epidural anesthesia is a requirement.
B. Use o preoperative carbohydrate drink hastens
the return o bowel unction.
C. ERAS has been shown to decrease non-surgical
complications.
D. ERAS has been shown to decrease length o stay
but has a higher readmission rate.
E. T ere is no need to start a ERAS protocol
because the national standard or length o stay
is 10 days.
ANSWERS
1. A. Hereditary syndromes o the gastrointestinal
tract account or 5% to 10% o GI malignancies
including colon cancer. T ere are several known
such syndromes: Lynch syndrome ( ormerly Heredi-
tary non-polyposis colorectal cancer), adenomatous
polyposis syndromes including FAP- amilial poly-
posis syndrome, AFAP-attenuated amilial polyposis
syndrome and MAP-MU HY-associated polypo-
sis, Peutz-Jegher syndrome, Juvenile Polyposis syn-
drome, Cowden syndrome, Serrated/Hyperplastic
Polyposis syndrome, and the conditions o Heredi-
tary Pancreatic Cancer, and Gastric Cancer. All o
these syndrome increase the risk o colorectal cancer
development and in the case o the FAPs, all o these
patients will progress to malignancy.
Lynch syndrome (LS): T is is the most common
hereditary syndrome and these patients have a mis-
match repair gene mutation. T e average age o colo-
rectal cancer diagnosis is 44 to 61 years (sporadic
cancer is 69 years). LS is also hallmarked by right-
sided colon predominance and rapid progression
rom adenomatous polyp to cancer (35 months). All
newly diagnosed colorectal cancer patients should
be genetically screened or LS mutations. For those
amily members at risk, screening with colonoscopy
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should begin at 20 to 25 years and continued at least
every 2 years.
Adenomatous Polyposis syndromes: T ere are
three variants: milial adenomatous polyposis (FAP),
attenuated FAP (AFAP), and molecular adenoma-
tous polyposis (MAP). 100% o FAP patients will go
on to develop colon cancer with an average onset o
39 to 41 years o age. T is condition is hallmarked
by > 100 synchronous polyps. Colon cancer screen-
ing should begin at age 10 to 12 via colonoscopy and
should continue annually; and ortunately, screening
with subsequent surgery can eliminate the mortality
rom this disease. In AFAP, the amount o colonic
polyps is reduced to about 50% and correspond-
ingly the average age o malignant onset is higher
at 58 years and occurs in about 69% o patients with
AFAP. Screening is recommended to begin in the
third decade o li e and continued every 1 to 2 years.
In MAP patients, cancer develops in 41% to 100% o
patients with average age o onset o 58 years. T ere
are typically 20 to 99 synchronous polyps. Here the
MU YH is a base excision repair gene and its muta-
tion causes the oncogenesis. In addition to other
malignancies, APSs are associated with desmoids
tumors.
Prophylactic colectomy, meaning total colectomy
with ileo-rectal anastomosis or total proctocolec-
tomy with ileal pouch-anal anastomosis, should be
considered in the late teens and early 20s and i there
is evidence o high-grade dysplasia, polyps > 10 mm
in diameter, marked increases in polyp number rom
one exam to the next, and i symptoms are present.
Peutz-Jegher syndrome (PJS): PJS is hallmarked by
hamartomatous polyps o the GI tract and mucocu-
taneous pigmentation. Colon cancer develops in 39%
o patients with an age o onset o 42 to 44. More
commonly patients will present with abdominal pain
due to one o the hamartomatous polyps causing an
intussusception. T is typically occurs in younger
patients. T ose with a suspected diagnosis or at risk
should have screening colonoscopy and esophago-
gastroduodenoscopy (EGD, or duodenal and gastric
cancer risk) at age 8. I polyps are ound and can be
controlled endoscopically, then surveillance is rec-
ommended or every 3 years. I no polyps are ound
and the patient is asymptomatic, the next screening
by endoscopy can be delayed until 18 years o age and
then every 3 years. While COX-2 inhibitors are theo-
retically believed to eliminate the polyps, there is no
conclusive evidence that they are help ul in doing so.

Juvenile Polyposis syndrome (JPS): JPS is de ned
by the presence o 5 or more juvenile polyps in the
GI tract, which can present in the rst decade o li e.
T e average age o diagnosis or JPS is 18 years o
age with the mean age o colon cancer onset being
34 years o age. By this age, 17% to 22% o carriers will
have developed colon cancer. Endoscopic screening
with both EGD and colonoscopy should begin at age
12 with surveillance done every 1 to 3 years.
Cowden syndrome (CS): 95% o CS patients have
colonic polyps, typically hamartomatous in nature,
and they can be numerous, even over 100. CS is also
associated with ganglioneuromas and it carries a
9% to 16% increased risk or colon cancer. Screen-
ing should begin at age 15 and continued every 1 to
2 years.
Serrated Polyposis syndrome (SRS): SRS was pre-
viously known as hyperplastic polyposis syndrome
when it was elt that the only types o polyps present
were serrated hyperplastic ones; but in act, the pol-
yps can be adenomatous also. All o the polyps are
serrated however. T e diagnosis can be con rmed
clinically in patients who have > 5 serrated polyps
proximal to the sigmoid colon with at least 2 o them
being > 10 mm, or any number o serrated polyps
proximal to the sigmoid colon and a rst degree rela-
tive with the diagnosis, or > 20 serrated polyps dis-
tributed throughout the colon. While SRS is elt to
increase the risk o colorectal cancer, the exact risk
is unknown. T e screening age is unknown but once
it is diagnosed, colonoscopy is recommended every
1 to 3 years.
2. C. T e initial work up or a patient who presents
with painless hematochezia should be a colonos-
copy. Alternatively a f exible sigmoidoscopy and
an air-contrast barium enema (ACBE) together
could be used to evaluate the hematochezia as most
lesions, including malignancies, will be in the rectum
and sigmoid colon. I a lesion is ound in the proxi-
mal colon on ACBE, then a colonoscopy will need
to be done in order to biopsy the lesion. An ACBE
alone would likely miss a lesion in the sigmoid colon
because the redundancy and mobility o the sig-
moid colon prevents adequate visualization o this
area. Rigid proctoscopy, in such a patient, is gener-
ally reserved or accurately measuring the distance
the lesion is rom the anal verge. It would, there ore,
not be used or diagnostic purposes to evaluate the
entire colon.
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C H AP TER 4 9 CO LO N C AN C ER 173
Fecal Immunochemical esting (FI ) and Stool
DNA testing are other screening tests used to detect
the presence o cancer or advanced adenomas. Both
are considered to be speci c and sensitive in the
detection and absence o CRC but their exact role
has yet to be de ned. Likely they would be used as
screening tools in average risk patients. Positive FI
or stool DNA tests would prompt the per ormance
o a colonoscopy.
As this patient has atigue, albeit mild, the right
colon still needs to be evaluated. C virtual colonos-
copy would not be the rst diagnostic method in this
patient as it is generally used as a screening tool only
or asymptomatic patients or or patients who would
not tolerate sedation well. Additionally C colonog-
raphy has not proven to be as accurate as conventional
colonoscopy or lesions < 10 mm in diameter. Simi-
larly capsule endoscopy is accurate in diagnosing the
presence o a polyp but the accuracy decreases with
polyps smaller than 10 mm. Moreover, the number o
studies and the number o patients in these studies is
small compared to the other modalities. At this time
conventional colonoscopy remains the best diag-
nostic tool to rule out malignancy or patients with
symptomatic colorectal disease.
3. D. An extent o disease work up is recommended
prior to proceeding to surgery in cases o colon can-
cer. T e NCCN guidelines recommend a C scan o
the chest, abdomen, and pelvis. Routine preoperative
imaging has been shown to change the treatment
plan or operative plan in up to 14% o patients. In
addition to identi ying metastatic disease, preopera-
tive imaging can be help ul with stage, nodal status,
and location o the lesion. Rigid proctoscopy is only
needed or rectal cancer to better determine the dis-
tance o the lesion rom the anal verge to help deter-
mine i a low anterior resection can be done. One
need not repeat the colonoscopy because the lesion
has already advanced into the submucosa and de ni-
tive removal via endoscopy is not possible. Addition-
ally, the entire colon was examined with the use o
conventional colonoscopy in the last sentence o
question 2.
PE scan is more routinely used a er resection o
colon cancers to determine recurrence but this is not
mandatory. PE scan/C colonography are recom-
mended i the proximal colon cannot be examined
due to an obstructing lesion or i metastatectomy is
anticipated.
174 G EN ERAL S U RG ERY EXAM IN ATI O N AN D BO ARD REVIEW
4. E. Laparoscopic colonic resection continues to
be more popular and it has proven advantages o
decreased hospital length o stay, less post-operative
pain, decreased super cial surgical site in ection, and
decreased non-surgical complications. While robot
assisted laparoscopic surgery is touted that it will
decrease blood loss because o superior vision and
articulation o instruments, there is no proo that any
surgical outcomes, including operative time, associ-
ated injury, post-operative pain, need or reoperation,
and leak, are superior with use o a robot. Addition-
ally, use o the robot is theoretically elt to decrease
discom ort and injury to the surgeon, but this has yet
to be proven. Indeed there is no proven advantage
with use o a robot in laparoscopic surgery.
Single incision laparoscopic surgery (SILS), also
known as Single Port Access surgery or Laparo-
scopic Single Site surgery, was touted to reduce post-
operative pain, decrease recovery time, and improve
cosmetic outcomes, as all o the laparoscopic instru-
ments would be placed through a single < 4 cm
incision. SILS is technically more demanding than
traditional laparoscopic techniques. When com-
pared to standard multi-port laparoscopy, the SILS
approach is associated with a shorter length o stay.
Initially the use o laparoscopic surgery or colon
cancer resection was elt to increase the rate o port
S upe rior
me s e nte ric a .
Right colic
flexure
Middle colic a .
Right colic a .
Ile ocolic a .
Ce ca l a a .
Appe ndicula r a .
http://surgerybook.net/
site metastases, but this has not proven to be true.
T ere is no increase in metastatic disease with the
use o laparoscopy. Furthermore, the laparoscopic
approach is equivalent to the open one in terms o
oncologic outcomes.
5. C. T e Enhanced Recovery A er Surgery (ERAS)
protocols are designed to standardize the post-
operative course or commonly per ormed surger-
ies so that surgeons, nursing staf , other providers,
and the patients themselves know what the process
is or the patients post-operative care. ERAS proto-
cols have been shown to decrease the length o stay
a er colon surgery, as well as many other procedures.
In the case o colon surgery, ERAS is only used or
elective procedures. ERAS protocols or colon sur-
gery generally start prior to the surgical procedure.
T e basic tenants o the protocol include the patient
drinking a high-carbohydrate drink 2 hours prior to
their surgery, decreased intra-operative intravenous
uid use, non-narcotic pain control, ambulation on
the day o surgery, early removal o a urinary cath-
eter, and starting a clear liquid diet on the evening
a er surgery. T ere are many dif erent protocols
amongst hospitals, however, and none o the ten-
ants mentioned have individually proven bene cial
to decrease length o stay, hasten return o bowel
Infe rior
me s e nte ric a .
Le ft colic
flexure
Acce s s ory to
colic a .
Ma rgina l a .
Le ft colic a .
S igmoid a a .
S upe rior
re cta l a .

unction, or decrease complications with the excep-
tion that early urinary catheter removal decreases
post-operative urinary tract in ections. T us, while
an epidural may reduce the need or narcotic
pain medications, it is not a requirement or ERAS
protocols.
ERAS protocols have been shown to reduce post-
operative length o stay to about 5 to 7 days and they
have shown a reduction in non-surgical complica-
tions like pneumonia and myocardial in arction.
However, they have not shown a reduction in surgical
complications like bleeding, super cial surgical site
in ections, deep surgical site in ections, leaks, and so
on. T e readmission rate a er using ERAS protocol is
similar to non-protocol post-operative outcomes in
that 10% to 13% o patients are readmitted.
T e NSQIP data is used to track 30-day outcomes
or all surgeries per ormed at hospitals that partici-
pate. A length o stay o 8 days has been determined
as the national standard and those outside o 8 days
represent the bottom tenth percentile o hospitals
and are thus considered outliers. Length o stay, how-
ever, does not necessarily mean there are poorer out-
comes or patients.
BIBLIOGRAPHY
Bailey CE, Hu C-H, You YN, Kaur H, Ernst RD, Chang GJ.
Variation in positron emission tomography use a er
colon cancer resection. J Oncol Pract. 2015;11(3):
36372.
Evaluation o Genomic Applications in Practice and Preven-
tion (EGAPP) Working Group. Recommendations rom
the EGAPP working group: Genetic testing strategies in
newly diagnosed individuals with colorectal cancer aimed
http://surgerybook.net/
C H AP TER 4 9 CO LO N C AN C ER 175
at reducing morbidity and mortality rom Lynch Syn-
drome in relatives. Genet Med. 2009;11(1):3541.
Greco, M, et al. Enhanced recovery program in colorectal
surgery: a meta-analysis o randomized controlled trials.
World J Surg. 2014;38(6):153141.
Jarvinen HJ, et al. en years a er mutation testing or Lynch
Syndrome: Cancer incidence and outcome in mutation-
positive and mutation-negative amily members. J Clin
Oncol. 2009;27:47937.
Kijima S, et al. Preoperative evaluation o colorectal cancer
using C colonography, MRI and PE /C . World J Gastro-
enterolo. 2014; 20(45):1696475.
Kuhry E, et al. Long-term results o laparoscopic colorec-
tal cancer resection. Cochrane Database Syst Rev. 2008;
16(2):498504.
Sali L, et al. Role o preoperative C colonography in patients
with colorectal cancer. World J Gastroenterolo. 2014;20(14):
3795803.
Maggiori L, et al. Single-incision laparoscopy or colorectal
resection: A systematic review and meta-analysis o more
than a thousand procedures. Colorectal Dis. 2012;4(10):
64354.
Martin-Lopez, JE, et al. Comparison o the accuracy o C
colonography and colonoscopy in the diagnosis o colorec-
tal cancer. Colorectal Dis. 2014;16(3):829.
Mauchley DC, et al. Clinical utility and cost-ef ectiveness o
routine preoperative computed tomography scanning in
patients with colon cancer. Am J Surg. 2005;189(5): 5127.
Stracci F, Zorzi M, Grazzini G. Colorecatl cancer screening:
ests, strategies, and perspectives. Front Public Health.
2014;2:210.
Syngal S, et al. ACG Clinical Guideline: genetic testing and
management o hereditary gastrointestinal cancer syn-
dromes. Am J Gastroenterol. 2015;110: 22362.
rinh BB, Jackson NR, Hauch A , Hu , Kandil E. Robotic
versus laparoscopic colorectal surgery. JSLS. 2014;18(4):
e00187.
Vasen HF, et al. Guidelines or the clinical management o
amilial adenomatous polyposis. Gut. 2008;57:70413.
 50
Crohns Disease
Andrew T. Schlussel
A 28-year-old woman with a history o Crohns disease
presents to the emergency room with worsening diar-
rhea, >20 bowel movements a day, and a 10% loss in body
weight over the past 6 weeks. She has previously been
managed on 5-aminosalicylic acid and In iximab. Her
vital signs on evaluation are signi cant or a heart rate o
105 beats per minute and a temperature o 100.6F. Her
abdomen is so with mild le low quadrant tenderness,
and her rectal exam is normal. Her white blood cell count
is 15 103/L. She undergoes a computed tomographic
(C ) enterography that shows an ileosigmoid stula with
a surrounding three-centimeter rim enhancing uid col-
lection that abuts the abdominal wall, and a more proxi-
mal ileoileal stula. T ere is no ree air or ree uid.
1. A surgical intervention should be o ered or which
o the ollowing presentations o Crohns disease?
A. Enteroenteric stulas with mild symptoms.
B. Medically managed disease but on two medica-
tions.
C. New in ammatory changes o the terminal
ileum on radiographic ndings.
D. Ileosigmoid stula and associated diarrhea and
malnutrition.
E. Intra-abdominal abscess amenable to C -guided
percutaneous drainage.
2. In the absence o symptoms, malnutrition and
diarrhea, which o the ollowing is the best option
or the above patient?
A. Ileocecectomy
B. Enterectomy with primary hand sewn anasto-
mosis
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C. Enterectomy with stapled anastomosis
D. Non-operative management
E. Proximal diversion
3. Surgical management o the ileosigmoid f stula in
the above patient is best approached with which o
the ollowing techniques?
A. En bloc resection o all in amed tissue with
proximal diversion.
B. Debridement and primary closure o stula site
on sigmoid colon i there are no secondary signs
o in ammation.
C. Enterectomy, debridement o stula tract, and
segmental colectomy.
D. Small bowel resection with primary anastomosis
alone.
E. No surgical indications.
4. Which o the ollowing is true regarding the
medical management o enteroenteric f stulas?
A. In iximab has demonstrated some bene t in the
closure o intra-abdominal stulas.
B. In iximab has a higher rate o closure or intra-
abdominal stulas compared to perianal stulas.
C. T ere is no role or anti- umor Necrosis Factor
agents in the setting o Crohns disease.
D. T ere is no risk in postoperative anastomotic
complications with pre-operative use o an anti-
umor Necrosis Factor agent.
5. Which o the ollowing is true regarding the
development o cancer in Crohns disease?

A. T ere is a higher rate o a Crohns associated malig-
nancy in a stula tract compared to a stricture.
B. T e risk o colon cancer in Crohns disease is no
greater than the general population.
C. Surveillance colonoscopy is not indicated in a
patient with an ileosigmoid stula.
D. Colon cancer in the setting o Crohns disease
should be managed similar to the general popu-
lation.
E. Subtotal colectomy with ileorectal anastomosis
has better outcomes in Crohns disease than a
segmental colectomy.
ANSWERS
1. D. Crohns disease was rst described in 1932. It
involves in ammation o the entire gastrointestinal
tract rom mouth to anus, and 50% o patients present
with ileocolic disease. T e Vienna system, published in
2000, is most commonly used or the classi cation
o Crohns disease. It includes: 1. Penetrating or s-
tulizing; 2. Stricturing; and 3. Non-penetrating, non-
stricturing Crohns disease. Surgical management o
this disease is reserved or patients who ail medical
treatment or who present with complications that
include: hemorrhage, per oration, abscess, stula,
strictures, malignancy, and growth retardation in
children. Percutaneous drainage o an intraabdomi-
nal abscess in an otherwise stable patient should be
considered prior to an operative intervention.
2. D. Patients with Crohns disease o en undergo mul-
tiple abdominal operations with 40% to 55% requir-
ing an operation 10 years ollowing their diagnosis,
and 75% requiring surgery in their li etime. Surgery
is not recommended or asymptomatic enteroenteric
stulas. However, exacerbation o diarrhea with asso-
ciated malnutrition is an indication or resection.
3. B. A systematic approach to the surgical manage-
ment o Crohns disease is critical to the preserva-
tion o bowel length. Nutrition should be optimized
as tolerated and preoperative studies to include
esophagogastroduodenoscopy, colonoscopy, and C
enterography should be considered. It is critical to
determine the site o in ammation, as o en times
the colon only needs to be debrided with primary
closure o the stula site. Only the diseased portion
o colon or small bowel should be removed. How-
ever, healthy bowel should be excised i the stula
is compromising the mesentery. Resection should
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C H AP TER 5 0 C Ro H n s D i s EAs E 17 7
only be per ormed back to grossly normal appearing
bowel.
4. A. In iximab is a human chimeric antibody directed
against the pro-in ammatory cytokine tumor necrosis
actor ( NF). T is therapy was one o the original
monoclonal antibodies to show improvement o symp-
toms, complete endoscopic remission and a decreased
need or surgery in Crohns disease. In iximab has
been used in the treatment o stulizing Crohns dis-
ease. In a review o 26 patients with stulizing Crohns
disease, in iximab alone was able to result in a com-
plete closure; however, only one was intra-abdominal.
T e ACCEN II study published in 2004 evalu-
ated the maintenance dosing o in iximab in patients
with stulizing Crohns who responded to induc-
tion therapy. T e majority o patients had perianal
stulas. T is study showed complete stula closure
in 36% o patients at 54 weeks. When evaluated by
location, approximately 97% o perianal stulas had
complete closure, demonstrating the superior out-
comes compared to intra-abdominal stulas.
Anti- NF agents will impede the immune
response ollowing surgery. El-Hussuna and col-
leagues per ormed a systemic review o post-operative
complications ollowing the use o anti- NF alpha
agents within three months prior to an operation.
Fourteen studies were reviewed, and overall there
was no dif erence in anastomotic complications
(7.6% vs. 8.2% in the control groups). In a subgroup
analysis, studies determined to have a lower chance
o bias identi ed a greater risk o adverse events with
the administration o anti- NF agents.
5. D. T e risk o colorectal cancer in Crohns disease
is a controversial topic, with some reports o up to
a 20- old increase in risk compared to the general
population. Lovasz and colleagues in 2013 demon-
strated the rate o colorectal cancer to be 5.5% a er
5 years, and 7.5% a er 10 years o disease duration,
with a greater prevalence in stricturing disease. Fur-
thermore, it was recommended to employ closer
endoscopic surveillance compared to the general
population ollowing diagnosis.
Surveillance colonoscopy or Crohns disease is
recommended at similar time intervals as ulcerative
colitis; beginning 8 to 10 years a er disease onset or
pancolitis, 15 years or le -sided disease, and then
annually a er 30 years ollowing diagnosis. Surgi-
cal management o a Crohns associated malignancy
17 8 G En ERAL s U RG ERY EXAM i n ATi o n An D Bo ARD REVi EW
should be treated like the general population with
segmental resection and associated lymphadenec-
tomy. T ere have been reports that recommend sub-
total colectomy in the setting o a Crohns associated
colorectal cancer due to the risk o synchronous and
metachronous lesions.
BIBLIOGRAPHY
Castellano J, Frank MS, Brandt LJ, Mahadevia P. Metachro-
nous carcinoma complicating crohns disease. Arch Intern
Med. 1981;141(8):10745.
Cooper DJ, Weinstein MA, Korelitz BI. Complications o
crohns disease predisposing to dysplasia and cancer o the
intestinal tract: Considerations o a surveillance program.
J Clin Gastroenterol. 1984;6(3):21724.
Crohn BB, Ginzburg L, Oppenheimer GD. Regional ileitis: A
pathologic and clinical entity. 1932. Mt Sinai J Med. 2000;
67(3):2638.
El-Hussuna A, Krag A, Olaison G, Bendtsen F, Gluud LL. T e
ef ect o anti-tumor necrosis actor alpha agents on post-
operative anastomotic complications in crohns disease: A
systematic review. Dis Colon Rectum. 2013;56(12):142333.
Gasche C, Scholmerich J, Brynskov J, et al. A simple classi-
cation o crohns disease: Report o the working party
or the world congresses o gastroenterology, vienna 1998.
Inf amm Bowel Dis. 2000;6(1):815.
Jess , Winther KV, Munkholm P, Langholz E, Binder V. Intes-
tinal and extra-intestinal cancer in crohns disease: Follow-
up o a population-based cohort in copenhagen county,
Denmark. Aliment Pharmacol T ere. 2004;19(3):28793.
http://surgerybook.net/
Lovasz BD, Lakatos L, Golovics PA, et al. Risk o colorectal
cancer in crohns disease patients with colonic involvement
and stenosing disease in a population-based cohort rom
Hungary. J Gastrointestin Liver Dis. 2013;22(3):2658.
Lu KC, Hunt SR. Surgical management o crohns disease. Surg
Clin North Am. 2013;93(1):16785.
Peters CP, Eshuis EJ, oxopeus FM, et al. Adalimumab or
crohns disease: Long-term sustained bene t in a popula-
tion-based cohort o 438 patients. J Crohns Colitis. 2014;
8(8):86675.
Peyrin-Biroulet L, Lo us EV, Jr, Colombel JF, Sandborn WJ.
T e natural history o adult crohns disease in population-
based cohorts. Am J Gastroenterol. 2010;105(2):28997.
Poritz LS, Rowe WA, Koltun WA. Remicade does not abolish
the need or surgery in stulizing crohns disease. Dis Colon
Rectum. 2002;45(6):7715.
Sands BE, Anderson FH, Bernstein CN, et al. In iximab main-
tenance therapy or stulizing crohns disease. N Engl J
Med. 2004;350(9):87685.
Sands BE. New therapies or the treatment o in ammatory
bowel disease. Surg Clin North Am. 2006;86(4):104564.
Steele SR. Operative management o crohns disease o the
colon including anorectal disease. Surg Clin North Am.
2007;87(3):61131.
Strong SA, Koltun WA, Hyman NH, Buie WD, Standards
Practice ask Force o T e American Society o Colon
and Rectal Surgeons. Practice parameters or the surgical
management o crohns disease. Dis Colon Rectum. 2007;
50(11):173546.
Warren S, Sommers S. Cicatrizing enteritis as a pathologic
entity; analysis o 120 cases. Am J Pathol. 1948;24(3):475
501.
 51
Diverticulitis
Erik Roedel
A 47-year-old obese man presents to the emergency
room with a two day history o sharp, constant, le
lower quadrant pain that is worse with straining and
is associated with subjective evers. T is is the patients
rst episode o pain. His vital signs are normal and
he is in no distress. You are able to elicit moderate
tenderness in the le lower quadrant on exam, and a
complete blood count shows a mild leukocytosis o
13,000/L.
1. Regarding the patient described above, what is the
single best study to obtain in order to con rm your
suspected diagnosis?
A. Plain abdominal X-rays
B. Magnetic resonance imaging (MRI) o the abdo-
men
C. Computed tomographic (C ) scan o the abdo-
men and pelvis with IV and oral contrast
D. C scan o the abdomen and pelvis with rectal
contrast
E. Abdominal ultrasound
2. Regarding the treatment o acute, uncomplicated,
sigmoid diverticulitis in a reliable patient, what is
the most appropriate treatment plan?
A. Discharge with pain medication.
B. Discharge with oral (PO) antibiotics and close
ollow up.
C. Admission, IV antibiotics, and bowel rest.
D. Urgent exploratory laparotomy and resection o
the involved colon.
E. Discharge with PO antibiotics and planned lapa-
roscopic resection in 6 to 8 weeks.
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3. Regarding the indications or elective colon resec-
tion a er an episode o uncomplicated diverticu-
litis, which o the ollowing is the strongest
indication?
A. A patient with continued chronic symptoms that
ail to resolve with antibiotics.
B. I the rst episode occurs in a patient younger
than the age o 50.
C. A er the second episode o uncomplicated
diverticulitis.
D. A er the rst episode in order to prevent uture
per oration and abdominal sepsis.
E. A er three documented cases o uncomplicated
diverticulitis.
4. Regarding a similar patient who presents without
signs o sepsis but on imaging has evidence o
complicated diverticulitis with a 6 cm pelvic
abscess, what is the best treatment plan?
A. Discharge with PO antibiotics and close ollow
up.
B. Admission, IV antibiotics, and percutaneous
drainage.
C. Admission, IV antibiotics, and Laparoscopic
washout with drain placement.
D. Admission, IV antibiotics, laparoscopic washout
with drain placement, and planned laparoscopic
resection in 68 weeks.
E. Admission, IV antibiotics, and resection o the
diseased segment with end colostomy.
5. Regarding a patient who presents with similar sym-
ptoms and early signs o sepsis and an abdominal
18 0 G EN ERAL S U RG ERY EXAM IN ATI O N AN D BO ARD REVIEW
exam consistent with dif use peritonitis, what is
the best course o action?
A. Admission, IV antibiotics, and percutaneous
drainage.
B. Admission, IV antibiotics, and Laparoscopic
washout with drain placement.
C. Admission, IV antibiotics, laparoscopic washout
with drain placement, and planned laparoscopic
resection in 68 weeks.
D. Admission, IV antibiotics, and proximal diver-
sion without resection.
E. Admission, IV antibiotics, and operative therapy
with resection o the diseased segment.
ANSWERS
1. C. Multi-slice C has become the standard imag-
ing modality to con rm the diagnosis o sigmoid
diverticulitis. It has been shown to have a sensitivity
and speci city as high as 98% and 99% respectively
with intravenous and intra-luminal contrast. A C
scan is use ul to con rm the diagnosis o diverticu-
litis, determine disease severity, and guide treatment.
Despite the accuracy o cross-sectional imaging in
the detection o diverticulitis, it may provide a diag-
nostic dilemma, as radiographically a colonic neo-
plasm can appear similar. T ere ore, colonoscopy is
recommended a er the acute process has subsided.
Plain radiographs o the abdomen are inexpen-
sive, easily available, and expose the patient to mini-
mal radiation. However, they o er limited diagnostic
in ormation in the evaluation o diverticulitis. Mag-
netic resonance imaging (MRI) and ultrasound may
be a use ul alternative in a patient where a C scan
or intravenous contrast is contraindicated. Ultra-
sound in some studies has diagnostic accuracy up
to 97%; however, it is limited by operator variability,
patient discom ort, and inability to accurately make
an alternative diagnosis. MRI is not limited by the
same issues as ultrasound and has a sensitivity and
speci city as high as 94% and 92% in some studies.
2. B. Recent publications have questioned the patho-
physiology o uncomplicated diverticulitis and have
disputed the need or antibiotics in these cases. How-
ever, current guidelines recommend that the stand-
ard treatment o acute uncomplicated diverticulitis
in the United States is outpatient antibiotic therapy.
T is is supported by the American Society o Colon
and Rectal Surgeons (ASCRS) and will continue until
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there is signi cant evidence supporting the sa ety o
outpatient management without antibiotics. o be a
candidate or outpatient therapy the patient must be
stable, non-toxic, reliable, able to maintain an ade-
quate enteral diet, and have uncomplicated disease.
Finally, the patient should have close interval ollow-
up to ensure their symptoms are improving.
3. A. T e current indications or elective resection
in diverticulitis include chronic symptoms, com-
plicated disease, inability to rule out a malignancy,
and patient speci c actors. T e surgical manage-
ment o uncomplicated diverticulitis has changed.
Previous retrospective studies, per ormed prior to
the use o C scan, reported recurrence in one third
o patients a er an uncomplicated episode. Recent
data has shown not only a lower recurrence rate,
13% to 23%, but more importantly, a low risk o
complicated disease and need or emergent surgery.
Due to these ndings, ASCRS recommends against
routine sigmoid resection or the indications o :
two or more uncomplicated episodes, age o < 50,
or to prevent complicated disease in the uture. T e
guidelines recommend that each patient be evalu-
ated individually regarding their overall health, age,
access to care, number, severity, and requency o
episodes, as well as the impact o each episode on
the patients quality o li e. T ese multiple actors
should be weighed against the risks associated with
elective resection. T ought ul counseling can be
per ormed with the patient, and an in ormed deci-
sion can be made.
As a subgroup, immune-compromised patients
have been ound to be at a higher risk o mortality
with non-operative treatment; there ore, surgeons
should have a lower threshold or resection in this
patient population.
4. B. T e treatment o complicated diverticulitis with
an associated abscess has drastically changed with
the advent o image-guided percutaneous drainage.
A treatment plan o antibiotics with selective drain-
age has been shown to allow up to 75% o patients
with a diverticular abscesses to avoid urgent surgery.
Percutaneous drainage is bene cial as a bridge or
stable patients without signs o peritonitis that would
have previously needed an urgent operation. Drain-
age provides patients the opportunity o an elective
single stage resection, the avoidance o surgery in
the acute in ammatory stage, a lower risk o ostomy

placement, and an overall decrease in morbidity and
mortality.
Currently, there is no data to support the outpa-
tient management o acute complicated diverticuli-
tis. Regarding the decision or elective resection a er
an episode o complicated diverticulitis, ASCRS
recommends that resection should be considered
in all patients that are appropriate surgery candi-
dates. However, C scan ndings o a phlegmon
or extraluminal gas alone does not indicate com-
plicated disease. Finally, there is insuf cient data to
show that laparoscopic lavage is a sa e alternative to
resection in patients with purulent or eculent peri-
tonitis. ASCRS does not currently support opera-
tive therapy without resection or the treatment o
diverticulitis.
5. E. T e treatment or patients with complicated diver-
ticulitis with evidence o purulent or eculent perito-
nitis is an operative approach with resection o the
diseased bowel. T ere is ongoing research in Europe
to determine i there is a role or laparoscopic lav-
age in patients with severe complicated diverticulitis.
However, as stated earlier, ASCRS does not currently
support non-resectional therapy except in the rare
circumstance that the abdomen is too hostile or
extirpation o the colon. Previous literature has
evaluated diversion without resection, but this tech-
nique was shown to have an increased rate o post-
operative peritonitis as compared to resection.
In general, the extent o resection should include
the entire sigmoid colon with a proximal margin o
so and pliable descending colon. While not all the
diverticula need to be removed, it is important to
ensure that none are included in the anastomosis i
one is per ormed. T e distal aspect o the specimen
should include a margin o normal rectum in order
to reduce the risk o recurrence.
T e decision to per orm a primary anastomo-
sis with or without protective ileostomy versus end
colostomy in the setting o emergent surgery or
diverticulitis is currently being debated. T ere is
nonrandomized and retrospective data that sup-
ports primary anastomosis. It was ound to be sa e
and not associated with worse outcomes in the set-
ting o complicated diverticulitis. T e inherent selec-
tion bias in these studies has prevented the surgical
community rom making broad recommendations
regarding primary anastomosis in the setting o
emergent colectomy or diverticulitis.
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C H AP TER 5 1 D I VERTI C U LITIS 181
BIBLIOGRAPHY
Abbas S. Resection and primary anastomosis in acute compli-
cated diverticulitis, a systematic review o the literature. Int
J Colorectal Dis. 2007;22(4):3517.
Alonso S, Pera M, Pares D, et al. Outpatient treatment o
patients with uncomplicated acute diverticulitis. Colorectal
Dis. 2010;12(10):e27882.
Ambrosetti P, Chautems R, Soravia C, Peiris-Waser N, errier F.
Long-term outcome o mesocolic and pelvic diverticular
abscesses o the le colon: A prospective study o 73 cases.
Dis Colon Rectum. 2005;48(4):78791.
Ambrosetti P, Jenny A, Becker C, errier F, Morel P. Acute le
colonic diverticulitis-compared per ormance o computed
tomography and water-soluble contrast enema: Prospec-
tive evaluation o 420 patients. Dis Colon Rectum. 2000;
43(10):13637.
Anaya DA, Flum DR. Risk o emergency colectomy and colos-
tomy in patients with diverticular disease. Arch Surg. 2005;
140(7):6815.
Baker ME. Imaging and interventional techniques in acute
le -sided diverticulitis. J Gastrointest Surg. 2008;12(8):
13147.
Broderick-Villa G, Burchette RJ, Collins JC, Abbas MA, Haigh
PI. Hospitalization or acute diverticulitis does not man-
date routine elective colectomy. Arch Surg. 2005;140(6):
57681; discussion 5813.
Chabok A, Pahlman L, Hjern F, Haapaniemi S, Smedh K,
AVOD Study Group. Randomized clinical trial o antibiot-
ics in acute uncomplicated diverticulitis. Br J Surg. 2012;
99(4):5329.
Constantinides VA, ekkis PP, Senapati A, Association o
Coloproctology o Great Britain Ireland. Prospective mul-
ticentre evaluation o adverse outcomes ollowing treat-
ment or complicated diverticular disease. Br J Surg. 2006;
93(12):150313.
Constantinides VA, ekkis PP, Athanasiou , et al. Primary
resection with anastomosis versus Hartmanns procedure
in nonelective surgery or acute colonic diverticulitis: A
systematic review. Dis Colon Rectum. 2006;49(7):96681.
Destigter KK, Keating DP. Imaging update: Acute colonic
diverticulitis. Clin Colon Rectal Surg. 2009;22(3):14755.
de Korte N, Ulna C, Boermeester MA, et al. Use o antibiot-
ics in uncomplicated diverticulitis. Br J Surg. 2011;98(6):
7617.
Dozois EJ. Operative treatment o recurrent or complicated
diverticulitis. J Gastrointest Surg. 2008;12(8):13213.
Eglinton , Nguyen , Raniga S, et al. Patterns o recurrence
in patients with acute diverticulitis. Br J Surg. 2010;97(6):
9527.
Etzioni DA, Chiu VY, Cannom RR, et al. Outpatient treatment
o acute diverticulitis: Rates and predictors o ailure. Dis
Colon Rectum. 2010;53(6):8615.
Feingold D, Steele SR, Lee S, et al. Practice parameters or
the treatment o sigmoid diverticulitis. Dis Colon Rectum.
2014;57(3):28494.
Forgione A, Leroy J, Cahill RA, et al. Prospective evaluation o
unctional outcome a er laparoscopic sigmoid colectomy.
Ann Surg. 2009;249(2):21824.
18 2 G EN ERAL S U RG ERY EXAM I N ATIO N AN D BO ARD REVI EW
Hall JF, Roberts PL, Ricciardi R, et al. Long-term ollow-up
a er an initial episode o diverticulitis: What are the pre-
dictors o recurrence? Dis Colon Rectum. 2011;54(3):2838.
Holmer C, Lehmann KS, Engelmann S, et al. Long-term out-
come a er conservative and surgical treatment o acute
sigmoid diverticulitis. Langenbecks Arch Surg. 2011;396(6):
82532.
Hwang SS, Cannom RR, Abbas MA, Etzioni D. Diverticulitis
in transplant patients and patients on chronic corticoste-
roid therapy: A systematic review. Dis Colon Rectum. 2010;
53(12):1699707.
Janes S, Meagher A, Frizelle FA. Elective surgery a er acute
diverticulitis. Br J Surg. 2005;92(2):13342.
Lameris W, van Randen A, Bipat S, et al. Graded compres-
sion ultrasonography and computed tomography in acute
colonic diverticulitis: Meta-analysis o test accuracy. Eur
Radiol. 2008;18(11):2498511.
http://surgerybook.net/
Salem L, Flum DR. Primary anastomosis or Hartmanns pro-
cedure or patients with diverticular peritonitis? A system-
atic review. Dis Colon Rectum. 2004;47(11):195364.
Sarma D, Longo WE, NDSG. Diagnostic imaging or diver-
ticulitis. J Clin Gastroenterol. 2008;42(10):113941.
Shabanzadeh DM, Wille-Jorgensen P. Antibiotics or uncom-
plicated diverticulitis. Cochrane Database Syst Rev. 2012;
11:CD009092.
Stollman N, Raskin JB. Diverticular disease o the colon. Lan-
cet. 2004;363(9409):6319.
T aler K, Baig MK, Berho M, et al. Determinants o recur-
rence a er sigmoid resection or uncomplicated diverticu-
litis. Dis Colon Rectum. 2003;46(3):3858.
Zeitoun G, Laurent A, Rou et F, et al. Multicentre, random-
ized clinical trial o primary versus secondary sigmoid
resection in generalized peritonitis complicating sigmoid
diverticulitis. Br J Surg. 2000;87(10):136674.
 52
Colon, Rectum, and
AnusRectal Cancer
Ronald A. Gagliano, Jr.
A 48-year-old white man presents to your o ce with a
history o seven months o intermittent painless blood
per rectum with bowel movements, which was diagnosed
as internal hemorrhoids by his primary care provider. He
has no other medical problems and has an unknown am-
ily history because he was adopted as an in ant. On your
digital and anoscopic evaluations, you nd scant bloody
mucous, no pathologic hemorrhoids, no other anal dis-
eases, and the visualized area o rectal mucosa is normal.
1. What is the next best step in his evaluation?
A. Immunohistochemical ecal occult blood test
B. Guaiac ecal occult blood test
C. Colonoscopy
D. Computed tomographic (C ) colonography
E. Flexible sigmoidoscopy
2. A exible endoscopic examination demonstrates
an endoscopically unresectable mass lesion
concerning or cancer is located at approximately
14 cm rom the anal verge and a biopsy is per or-
med. T e next best step to evaluate the lesion is?
A. C scan o the pelvis
B. Rigid proctoscopy
C. Serum carcinoembryonic antigen (CEA) level
D. Hepatic unction tests
E. Fusion positron emission tomography (PE )/
C scan o the chest, abdomen, and pelvis
3. A colonoscopy shows no other lesions. High resolu-
tion C scans o the chest, abdomen, and pelvis do
not demonstrate distant disease and recommended
blood tests demonstrate only a mild anemia.
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Pathologic evaluation returns a diagnosis o
moderately dif erentiated adenocarcinoma, about 9
cm rom the anal verge. What i any tests remain to
complete the pre-treatment staging?
A. ransabdominal liver ultrasound
B. KRAS mutation genotype
C. Fusion PE /C scan o the chest, abdomen, and
pelvis
D. No urther evaluation is necessary.
E. Magnetic resonance imaging (MRI) o the pelvis
4. Preoperative staging reveals a 4 cm moderately
dif erentiated adenocarcinoma 2N1M0 located
at 9 cm rom the anal verge. What is the pre erred
treatment strategy?
A. Pre-operative chemotherapy ollowed by chemo-
radiation therapy ollowed by ull thickness
transanal excision o the primary lesion.
B. Low anterior resection o the rectum ollowed by
chemotherapy or chemoradiation therapy based
on pathologic evaluation o the resection speci-
men.
C. Pre-operative chemotherapy ollowed by chemo-
radiation therapy ollowed by low anterior
resection o the rectum.
D. Chemoradiation ollowed by low anterior resec-
tion o the rectum.
E. Pre-operative chemotherapy ollowed by chemo-
radiation therapy ollowed ull thickness trans-
anal excision o the primary lesion.
5. Regarding additional testing to evaluate the
patient, which is recommended and demonstrated
18 4 G EN ERAL S U RG ERY EXAM IN ATIO N AN D BO ARD REVI EW
to be cost ef ective or all rectal cancer patients
under 50?
A. Somatic APC gene sequencing
B. umor gene sequencing
C. Circulating tumor cells
D. Hypermethylation analysis o tumor DNA
E. Mismatch repair protein analysis and/or micro-
satellite instability analysis
ANSWERS
1. C. T e diagnostic concern in this patient is primar-
ily cancer, as the most likely other causes o painless
rectal bleeding have been ruled out based on in o ce
evaluation. Other likely diagnoses to consider would
be some orm o colitis or bleeding diverticulosis,
but these are less likely due to the lack o abdomi-
nal symptoms, bleeding only with bowel movements.
From the choices listed, the immunohistochemi-
cal ecal occult blood test (iFOB ) and Guaiac ecal
occult blood test (gFOB ) are designed to detect
blood in the GI tract; there ore, they do not advance
the patients work up as he has visible gross blood in
his bowel movements. Both exible sigmoidoscopy
and colonoscopy have the ability to diagnose and
biopsy cancers, but only colonoscopy can evaluate
the entire colon and possibly treat the source o the
bleeding. In a comparison o our diagnostic strat-
egies or adult rectal bleeding, colonoscopy was the
best overall strategy. C colonography is controver-
sial in its utility in colorectal cancer screening, but it
is not recommended in the evaluation o the symp-
tomatic patient, with sensitivity that is not equivalent
to beroptic endoscopy.
2. B. T e location o the lesion is critical or the next
phases o the evaluation and management o this
tumor, as there are signi cant di erences in the eval-
uation and management o certain stages o colon
versus rectal cancers, as well as very proximal versus
middle and distal rectal cancers. Flexible endoscopy
is notoriously unreliable with regards to accurate
measurement o a distal lesion, and generally over-
estimates the distance rom the verge. Rigid proctos-
copy is mandatory or any lesion in the rectum or
recto-sigmoid junction, as it is reliable in its results.
It ideally should be per ormed by the operating sur-
geon. umors with the distal most aspect located
above 12 cm rom the anal verge are diagnosed as
colon cancer and below 12 cm are diagnosed as
http://surgerybook.net/
rectal cancer. However, tumors diagnosed in the rec-
tum rom 10.1 cm to 11.9 cm rom the anal verge can
be treated as colon cancers, as there seems to be no
bene t or local control rom neoadjuvant or adju-
vant chemoradiation therapy. C is part o the stag-
ing o colorectal cancer, but C o the pelvis alone
is incomplete or staging, and both endorectal ultra-
sound in skilled hands and 3.0 MRI o the pelvis
are better modalities to evaluate or local disease and
pelvic regional metastasis. Serum CEA is indicated
until a colon or rectal cancer is diagnosed by biopsy,
but it is not the next best step. Further, it does not
advance the patients evaluation at this time. Hepatic
unction tests are unhelp ul and not indicated unless
there is coexistent liver disease. PE /C scan does
not replace a high resolution C o the chest, abdo-
men, and pelvis with oral and IV contrast, and is gen-
erally not indicated in the initial evaluation o colon
and rectal cancer.
3. E. T e lesion is now clearly a rectal adenocarcinoma
with no evidence o distant metastasis, giving us a
stage o xNxM0. What we need next is the tests that
determine the and N status in order to generate
our treatment plan, thereby making the choice o no
urther evaluation wrong. T e best test listed is the
MRI o the pelvis. T is test gives the most accurate
assessment o tumor depth and presence o nodal
metastasis without the user variability o endorectal
ultrasound. It is also the best test to assess the pos-
sibility o a threatened circum erential radial margin
by invasion o or near to the mesorectal ascia. Given
the normal C o the abdomen, there is no indication
or the liver ultrasound and again there is generally
no indication or the PE /C in the initial staging o
colorectal cancer, especially i a normal high resolu-
tion C scan is normal. KRAS mutation rom wild
type is use ul or predicting whether or not biologic
therapy will be use ul, but only in patients with meta-
static disease, which this patient does not have.
4. D. T e patient now can be staged as Stage IIIA and
the lower edge o the tumor is below 10 cm rom the
anal verge. Based on current guidelines, this patient
should have neoadjuvant chemoradiation therapy
ollowed by low anterior resection using a total mes-
orectal approach with a distal margin 4 cm rom the
tumor. T e transanal excision choices are incorrect
based on nodal status and tumor size o 4 cm and
location o the lower edge above 8 cm rom the anal
 C H AP TER 5 2 CO LO N , REC TU M , AN D AN U S REC TAL C AN C ER
verge. T e choice or low anterior resection (LAR)
rst then chemoradiation is wrong because in
patients who can tolerate the neoadjuvant therapy,
there is an absolute decrease in local recurrence o
about 7% (6% rom 13%) in these patients who get
chemoradiation prior to operation compared to af er
the operation, and is backed by category 1 data. T e
choice with chemotherapy then chemoradiation
then LAR is an option or care, but not pre erred in
this situation.
5. E. T e patient has no knowledge o his amily his-
tory, nor any timely way to get it, thereby making a
preoperative determination o his risk or a hereditary
colorectal cancer syndrome by Bethesda or Amster-
dam criteria impossible. Approximately 2% to 4%
o rectal cancers are known to be due to Hereditary
Non-Polyposis Colorectal Cancer (HNPCC) syn-
drome or Lynch syndrome. T is syndrome is caused
by germline mutation in any one o a number o genes
involved with the process o DNA Mismatch Repair
(MMR). Impairment o MMR results in accumula-
tion o length alterations in simple repeated DNA
ragments called microsatellites. T is accumulation
leads to a state o genetic instability termed Microsat-
ellite Instability (MSI). T e syndrome is urther char-
acterized by an increased incidence o cancers in the
emale genital system and the urinary system, as well
as data supporting an increase in brain, pancreatic
and gastric cancers in certain amilies. T e Evalua-
tion o Genomic Applications in Practice and Pre-
vention (EGAPP) working group o the CDC ound
it to be cost e ective or MMR and/or MSI testing
or all colorectal cancers in patients under 50 years
o age, and many cancer centers in the United States
test all patients under 70 and all patients regardless
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18 5
o age i the Bethesda or Amsterdam criteria are
met. Somatic APC gene sequencing is used to diag-
nose an index mutation in the amilial adenomatous
polyposis (FAP) syndrome. umor gene sequenc-
ing may be use ul in some settings, but not be ore
per orming the more rapid and cheaper testing or
Lynch syndrome. T e presence o circulating tumor
cells are being studied as a diagnostic tool or cancer
and cancer recurrence, but currently is not routinely
used. Hypermethylation analysis o tumor DNA is
not routinely done and is suggested as the cause o
cancer or patients with MMR protein abnormality
detected in hMSH1 and a BRAF mutation, rather
than a somatic mutation.
BIBLIOGRAPHY
Allen E, Nicolaidis C, Hel and M. T e evaluation o rectal
bleeding in adults. A cost-e ectiveness analysis comparing
our diagnostic strategies. J Gen Intern Med. January 2005;
20(1):8190. PMID:15693933.
Bipat S, Glas AS, Slors FJ, et al. Rectal cancer: Local staging
and assessment o lymph node involvement with endolu-
minal US, C , and MR imagingA meta-analysis. Radiol-
ogy. September 2004;232(3):77383.
Evaluation o Genomic Applications in Practice and Preven-
tion (EGAPP) Working Group. Recommendations rom
the EGAPP Working Group: Genetic testing strategies in
newly diagnosed individuals with colorectal cancer aimed
at reducing morbidity and mortality rom Lynch syndrome
in relatives. Genet Med. January 2009;11(1):3541.
NCCN Clinical Practice Guidelines in Oncology Rectal
Cancer v3. 2014. www.nccn.org/pro essionals/physicians_
gls/pd /rectum.pd .
NCCN Clinical Practice Guidelines in Oncology Colorectal
Cancer Screening v2.2013. www.nccn.org/pro essionals/
physicians_gls/pd /colon.pd .
Sauer R, Becker H, Hohenberger W, et al. Preoperative versus
postoperative chemoradiotherapy or rectal cancer. N Engl
J Med. October 21, 2004;351(17):173140.
 53
Perirectal Abscess
Alexander Malloy
A 40-year-old woman presents with a ve day history o
worsening gluteal and rectal pain. Her pain is dull and
constant and she describes a sensation o rectal ull-
ness. She has evers and chills. She has had no changes in
bowel habits and denies constipation. She denies puru-
lence, hematochezia, melena, or incontinence. She has
some discom ort with de ecation but no pain. She denies
a history o in ammatory bowel disease, hemorrhoids, or
rectal prolapse. She denies trauma to the area. She is not
sexually active. Her signi cant past medical and surgi-
cal history includes an appendectomy. In the emergency
department, she is ebrile to 102.3F, a heart rate o 103,
and a blood pressure o 120/83. She has some induration
and erythema 45 cm laterally and anterior to the anal
verge on the right with tenderness, no uctuance, normal
sphincter tone, no masses, and no induration. No stula
openings visible. Laboratory workup is signi cant only
or a white blood cell count o 19.2.
1. What would be the expected course o a f stula-in-
ano (i present)?
A. Radial to the posterior midline
B. Curvilinear to the anterior midline
C. Radial to the anterior midline
D. Curvilinear to the posterior midline
2. What is the pre erred operative management o
horseshoe abscesses?
A. Intravenous antibiotics
B. Presacral drainage
C. Incision and drainage with counter incision
D. Single incision and drainage
E. ransabdominal drainage
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3. Regarding the outcomes o treatment or anal
f stula, which o the ollowing is correct?
A. T ere is no di erence in stula closure rate
with brin glue versus standard stulotomy, but
those who underwent brin glue placement have
shorter recovery times.
B. Fistulas occur in 66% o patients who have peri-
rectal abscesses.
C. Non-cutting setons have an increased risk o
incontinence.
D. All anterior stulas in emales should be man-
aged with a cutting seton.
4. Regarding perirectal abscesses, which o the
ollowing is correct?
A. Horseshoe abscesses can occur in two planes and
usually require imaging or diagnosis.
B. Immunocompromised patients can be managed
with bedside incision and drainage and intrave-
nous antibiotics.
C. Crohns disease is responsible or the majority o
perirectal abscesses.
D. Necrotizing sof tissue in ection o the perianal
and perineal areas has a mortality rate approach-
ing 50%.
5. Regarding perirectal abscesses, which o the
ollowing is correct?
A. Supralevator abscesses can be a complication o
diverticulitis.
B. Perianal abscesses always require a counter inci-
sion.

C. Fistulas encountered at the time o incision and
drainage o a perirectal abscess should be surgi-
cally repaired.
D. External mani estations o intersphincteric
abscesses generally include a stula track.
ANSWERS
1. D. According to Goodsalls rule, the transverse anal
line generally dictates the course o a stula track.
External ori ces o a stula track posterior to the
transverse anal line course in a curvilinear ashion to
the posterior midline. External ori ces anterior to the
transverse anal line generally course in a radial ash-
ion to the anterior midline. However, i a stula is pre-
sent greater than 2 to 3 cm rom the anal verge, their
course does not ollow the traditional radial course to
the anterior midline. T ey typically produce curvilin-
ear tracks that may end at the posterior midline or just
lateral to the posterior midline. T is patients area o
induration and erythema oci is approximately 4 to
5 cm rom the anal verge and thus could be considered
a long anterior stula track; there ore, D is correct.
2. C. Horseshoe abscesses encompass almost the
entire circum erence o the rectum and can occur in
the supralevator plane, the ischiorectal plane, and the
intersphincteric plane. Each area o concern dictates
the clinical management. Intravenous antibiotics are
not adequate treatment or suppurative perirectal
disease and may predispose the patient to worsening
perirectal sepsis.
Presacral drainage is not the recommended treat-
ment or horseshoe abscesses and is reserved or rec-
tal injuries in the settings o trauma. Single incision
and drainage may be e ective in certain abscesses
but is generally not recommended in horseshoe
abscesses. Drainage may be inadequate or ine ec-
tive and counter incisions are pre erred which also
includes unroo ng o the external sphincter com-
plex. T is same modality is also pre erred in the set-
ting o a horseshoe stula.
ransabdominal drainage may be warranted in
certain clinical scenarios involving supralevator
abscesses when the origin o the abscess is intra-
abdominal in nature. ransabdominal drainage or a
cryptoglandular abscess runs the risk o inadequate
drainage and transsphinctertic stula ormation,
along with the risk o systemic sepsis due to inade-
quate drainage.
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C H AP TER 5 3 P ERi REC TAl Ab s C Es s 18 7
3. A. Fistula-in-ano represent a common chronic
problem af er perirectal abscess. Fibrin glue and con-
ventional stulotomy have similar outcomes or rates
o recurrence and closure o stula tracks, but brin
glue insertion may have shorter return to work times.
Fistulas occur in up to 25% to 50% o patients
who have perirectal abscess. Setons are placed to
promote drainage o stulas and to acilitate bro-
sis o the stula track. Cutting setons are gradually
tightened by the surgeon in the outpatient setting,
which eliminates the stula while gradually dividing
the sphincter complexes, putting the patient at risk
or incontinence.
Non-cutting setons have a signi cantly reduced
risk o incontinence when compared to cutting
setons, with some studies suggestive o preservation
o continent unction, and generally are accepted or
treatment o high intersphincteric stula tracks.
4. D. As stated earlier, horseshoe abscesses can occur
in the supralevator plane, the ischiorectal plane, and
the intersphincteric plane. Imaging is not necessary
or the diagnosis but does provide a help ul adjunct
to clinical correlation.
Immunocompromised patients should gener-
ally not be managed in the outpatient setting af er
incision and drainage o a perirectal abscess. T ey
may or may not mani est systemic or local signs o
in ammation and can present with delayed diag-
noses o sepsis or necrotizing sof tissue in ection.
T ese patients are generally managed with inpatient
admission, incision and drainage, and intravenous
antibiotic therapy. I the abscess is a super cial peri-
anal one, then incision, drainage, and packing may be
per ormed with close ollow-up.
Crohns disease mani ests in several di erent ways
and can certainly be the inciting actor or perirec-
tal abscesses and complex stula disease. However,
the most common cause o perirectal suppuration is
cryptoglandular ormation o in ection. Other causes
include malignancy, trauma, and hidradenitis suppu-
ritiva.
Necrotizing sof tissue in ection o the perirectal
and perineal region is a li e threatening process, as
is the disease in any sof tissue location. Intersphinc-
teric abscesses can of en go unnoticed or misdiag-
nosed and can result in a delayed diagnosis. In areas
without access to healthcare, perirectal disease can
progress rapidly as well. In ection can worsen and
spread through sof tissue planes, progressing to a
18 8 G EN ERAl s U RG ERY EXAM i N ATi O N AN D b O ARD REVi EW
Pe rire c tal abs c e s s e s
S upra le va tor
a bs ce s s
P e ria na l
a bs ce s s
necrotizing sof tissue in ection, requiring wide local
debridement. In some cases, the debridement is large
enough that a diverting colostomy is required or
wound healing. Mortality rates with necrotizing sof
tissue in ection are approximately 40% to 50%.
5. A. Supralevator abscess can occur as a result o intra-
abdominal pathology such as diverticular abscesses,
malignancy, or trauma. Perianal abscesses usually are
super cial, simple abscesses without stula tracks
and are treated with a single cruciate incision with
packing, there ore B is incorrect.
Fistulas encountered at the time o a perirec-
tal abscess are common. However, stulotomy is
generally not per ormed in the acute setting as no
improved clinical outcome has been documented
with acute management. Intersphincteric abscesses
generally have a more insidious clinical course and
plague the patient with complaints o vague discom-
ort without external mani estations. Induration and
tenderness can be elicited on a digital rectal exami-
nation but other ndings are of en inconsistent. T is
type o abscess requires an exam under anesthesia
or adequate treatment modalities.
BIBLIOGRAPHY
Cirocco WC, Reilly JC. Challenging the predictive accuracy
o Goodsalls rule or anal stulas. Dis Colon Rectum. June
1992;35(6):53742.
Le va tor
a ni mus cle
Is chioa na l (is chiore cta l)
Inte rna l Exte rna l a bs ce s s
s phincte r s phincte r
Inte rs phincte ric (intra mus cula r
or s ubmucos a l) a bs ce s s
Chung W, Kazemi P, Ko D, Sun C, Brown CJ, Raval M, et al.
Anal stula plug and brin glue versus conventional treat-
ment in repair o complex anal stulas. Am J Surg. May
2009;197(5):6048. doi:10.1016/j.amjsurg. 2008.12.013.
Dunn KM, Rothenberger DA. Colon, Rectum, and Anus.
In: Brunicardi, CF, et al. eds. Schwartzs Principles of Sur-
gery. 9th ed. New York, NY: McGraw-Hill Co.: 2010:
10604.
Henrichsen S, Christiansen J. Incidence o stula-in-ano
complicating anorectal sepsis: A prospective study. Br J
Surg. 1986;73:371372.
Huber P Jr, Kissack AS, Simonton C . Necrotising sof -tissue
in ection rom rectal abscess. Dis Colon Rectum. 1983; 26(8):
50711.
Nelson, H. Anus. In: ownsend CM et al. eds. Sabiston Text-
book of Surgery. 19th ed. Philadelphia, PA: Elsevier: 2012:
13926.
North JH Jr, Weber K, Rodriguez-Bigas MA, Meropol NJ,
Petrelli NJ. T e management o in ectious and nonin ec-
tious anorectal complications in patients with leukemia.
J Am Coll Surg. October 1996;183(4):3228.
Pezim ME. Success ul treatment o horseshoe stula requires
deroo ng o deep postanal space. Am J Surg. May 1994;
167(5):5135.
Sentovich SM, Fibrin glue or anal stulas: long-term results.
Dis Colon Rectum. April 2003;46(4):498502.
Vial M, Pars D, Pera M, Grande L. Faecal incontinence af er
seton treatment or anal stulae with and without surgi-
cal division o internal anal sphincter: a systematic review.
Colorectal Dis. 2010 Mar;12(3):1728. doi: 10.1111/j.1463-
1318.2009.01810.x.
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Br east Disease
Richard Smith

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 54
Breast Mass
Anita Mamtani
A 57-year-old, otherwise healthy emale presents to
your clinic to discuss the results o her recent screen-
ing mammogram. She has previously had unremark-
able screening mammograms since the age o 40. She
has two aunts with breast cancer, and recently heard
that her 35-year-old niece was diagnosed with invasive
ductal adenocarcinoma. She reports no palpable masses
noticed on breast sel -exams, no nipple drainage, no
breast skin changes, and no other concerning constitu-
tional symptoms.
1. T e patient requests counseling on various genetic
syndromes, given the young age o her recently
diagnosed niece. Which o the ollowing is
correctly matched?
A. BRCA1chromosome 13qincreased emale
and male breast cancer risk.
B. BRCA1chromosome 17qincreased emale
breast and ovarian cancer risk.
C. BRCA2chromosome 17qincreased emale
and male breast cancer risk.
D. Li-Fraumeni syndromeP EN mutation
increased breast, nervous system, and GI tract
cancers.
E. Peutz-Jehgers syndromeKRAF mutation
increased breast and colon cancer, mucocutane-
ous lesions.
2. T e patients screening mammogram reveals a 1.1. cm
density in the subareolar region o her le breast.
She promptly undergoes diagnostic mammogram
with ultrasound or urther evaluation o the lesion,
which the radiologist classif es as BIRADS 4B. She
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has no palpable lesion on physical exam. T e most
appropriate next step is:
A. Repeat mammography in 6 months.
B. Magnetic resonance imaging (MRI) o the breast.
C. Genetic screening or inherited mutations.
D. Stereotactic core needle biopsy.
3. Pathology reveals lobular carcinoma in situ (LCIS).
T e patient now seeks advice on her overall risk o
cancer. Which o the ollowing is true?
A. LCIS has a 40% li etime risk o development into
lobular carcinoma.
B. LCIS is not considered a precursor itsel , but
has an increased risk o malignancy in either
breast.
C. Ductal carcinoma in situ (DCIS) is not consid-
ered a precursor to malignancy.
D. LCIS and DCIS are both precursors to malig-
nancy.
E. LCIS is the most common type o in-situ breast
lesion.
4. T e patient opts to proceed with prophylactic
bilateral mastectomies. In discussion o operative
details, she mentions that her niece, who had Stage
I invasive ductal carcinoma with positive estrogen
receptor status, underwent a lumpectomy with
radiation. Which o the ollowing is true?
A. All patients bene t rom chemotherapy, regard-
less o nodal status.
B. Adjuvant therapy with tamoxi en results in sig-
ni cant prolongation o disease- ree and overall
192 G EN ERAL S U RG ERY EXAM I N ATI O N AN D BO ARD REVI EW
survival in patients with HER2/neu gene overex-
pression.
C. T e purpose o radiation is to decrease the risk
o distant metastasis.
D. Patients with early stage breast cancer who
undergo lumpectomy with sentinel lymph node
biopsy ollowed by radiation have similar sur-
vival rates as those who undergo ormal axillary
lymph node dissection.
E. Aromatase inhibitors may be help ul or adju-
vant therapy in pre-menopausal women.
5. At her ollow-up visit a er her operation, the
patient reports eeling a sensation o numbness in
her upper inner arm. She has ull motor strength
o the extremity, and the remainder o her arm
has normal sensation. Her incisions appear to be
healing well. What is the most likely etiology o
this?
A. Injury to cutaneous branches o the brachial
plexus.
B. Injury to the thoracodorsal nerve.
C. Injury to the intercostobrachial nerve.
D. Disruption o the lymphatic network.
E. Occult post-operative seroma in the axilla.
ANSWERS
1. B. T e BRCA1 gene is located on chromosome 17q,
and con ers an increased risk o emale breast and
ovarian cancer.
Breast cancer is the most common cancer in
women, and is second to lung cancer as a cause o
death in women, with a li etime risk o 1 in 8. Risk
actors or developing breast malignancy include
a amily history o breast cancer, early menarche,
late menopause, personal history o breast or uter-
ine cancer, and nulliparity. T e Gail Model is a tool
designed to calculate breast cancer risk by assess-
ing risk actors including personal medical history,
reproductive history, and history o breast cancer
among rst-degree relatives, and translating these
into a score to estimate risk o developing invasive
breast cancer over set periods o time.
Approximately 10% o breast cancers are heredi-
tary in nature. Genes and syndromes implicated in
hereditary BCA include, among others, the BRCA1
(chromosome 17q, increased emale breast and
ovarian cancer risk) and BRCA2 mutations (chro-
mosome 13q, increased ovarian cancer, and emale
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and male breast cancer risk), Li-Fraumeni syndrome
(p53 mutation, increased breast cancer, sarcoma, leu-
kemia, brain tumors), Cowdens syndrome (P EN
mutation, increased breast, nervous system, and GI
tract cancers), and hereditary non-polyposis colon
cancer (HNPCC, mismatch repair de ect, increased
colon, endometrial, ovarian, and breast cancers).
2. D. For BIRADS 4 or 5 lesions detected on screen-
ing studies, stereotactic core biopsy is considered the
pre erred rst step in pathologic diagnosis.
Clinical eatures concerning or breast cancer
include xed/ rm palpable masses, nipple retraction,
skin changes, and unilateral nipple discharge. Annual
mammography is valuable as a screening tool in
women 40 years in age, although is limited in
women younger than 35 due to increased breast den-
sity. Concerning mammographic ndings include an
architectual distortion, developing asymmetry, mass
(with partially or ill-de ned margins), or a cluster o
microcalci cations with amorphous, linear, branch-
ing patterns. Screening mammography in women 50
years and older has decreased breast cancer mortal-
ity by 33%. Ultrasound may be used to distinguish
solid and cystic masses. Magnetic resonance imaging
(MRI) is available as an adjunctive tool, but cannot
replace mammography or ultrasound. Fine needle
aspiration (FNA) yields simple cytological results but
cannot distinguish carcinoma in situ rom invasive
cancer because it does not include in ormation about
architecture. Core biopsy is considered the pre erred
rst step in pathologic diagnosis, particularly or
palpable lesions and or lesions detected on screen-
ing studies. In general, a two-step approach o initial
biopsy ollowed by de nitive operation, i indicated,
is the pre erred pathway o management.
3. B. LCIS is not considered a pre-cancerous lesion, but
is associated with an increased risk o malignancy in
either breast. amoxi en can decrease this risk, and
depending on tumor biology and individual patient
risk, management that may be advised includes close
observation with serial monitoring, chemopreven-
tion, or surgery.
DCIS is considered a precursor to ductal adeno-
carcinoma, the most common histologic type o
breast cancer, and is associated with a signi cant
increase in risk o ipsilateral cancer. 10% to 20% o
patients with newly-discovered DCIS already have
associated invasive carcinoma, and when untreated,

40% to 60% o these patients will develop ipsilat-
eral invasive ductal carcinoma. LCIS is not consid-
ered a precursor to invasive adenocarcinoma, but is
associated with a 20% to 30% risk o ductal adeno-
carcinoma in either breast. Lobular carcinoma com-
prises a smaller 10% o all invasive breast cancers.
In ammatory breast cancer is yet rarer and with the
worst prognosis o all breast cancer types, compris-
ing 5% o cases, with a characteristic rapid onset o
pain, visible breast edema, and skin changes (peau
dorange), and a median survival o 36 months. Skin
biopsy alone o en reveals unique tumor invasion o
lymphatic channels.
4. D. Multiple large randomized studies with long-
term ollow-up including the National Surgical
Adjuvant Breast and Bowel Project (NSABP) tri-
als and Milan series showed that disease- ree and
overall survival rates are similar in Stage I and II
patients treated with lumpectomy with axillary dis-
section ollowed by radiation, and those treated by
modi ed radical mastectomy. T is led to breast-con-
serving surgery with radiation to be a sa e and less
morbid course o treatment or patients with ame-
nable, early-stage breast cancer. T is has been the
historical approach to early breast cancer. T e Z11
trial showed that patients treated with breast conser-
vation therapy (lumpectomy + SLN biopsy + radia-
tion therapy) and who had a positive sentinel lymph
node had the same survival as those who underwent
completion axillary lymph node dissection or the
positive node. T is urther decreased the morbidity
o breast cancer surgery. T is makes D the correct
answer.
Upon discovering a new diagnosis o breast can-
cer, the stage must clearly be determined be ore
initiating treatment. Surgery is indicated or Stage
I to III disease, while Stage IV (metastatic) disease
is generally managed with medical and/or radia-
tion therapies. T e purpose o surgery is to obtain
local control by either lumpectomy or mastectomy,
and to evaluate nodal burden. Lumpectomy may be
done with or without pre-operative mammographic
needle-localization. ypes o mastectomy include
simple (removal o all breast tissue), radical (removal
o all breast tissue, pectoralis major, pectoralis minor,
and an axillary node dissection), and modi ed radi-
cal (removal o all breast tissue, pectoralis ascia
only, and an axillary node dissection). I nodes are
clinically negative, the pre erred method or stag-
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C H AP TER 5 4 BREAS T MAS S 193
ing axillary lymph nodes is sentinel node biopsy,
which is per ormed with methylene blue or 99m c
sul ur colloid, a radiopharmaceutical that is taken
up by lymphatic capillaries, transported to the sen-
tinel node, and then phagocytosed by macrophages.
A ormal axillary dissection is generally indicated in
the case o clinically positive nodes, or completion
axillary dissection in the case o clinically negative
nodes with ailed sentinel mapping. T e currently
evolving realm o neaodjuvant chemotherapy, with
potential or downstaging both the breast mass and
nodal metastases, continues to change the landscape
o breast cancer surgery.
Radiation is used to decrease the risk o local
recurrence, particularly when used as adjuvant to
breast-conserving surgery. Chemotherapy typically
consists o anthracycline and taxane agents, and may
be help ul or patients with positive nodal status and
high risk o relapse, but may generally be excluded in
patients with small tumors and negative lymph nodes.
Hormonal therapy has been known to decrease risk
o recurrence and mortality in patients with estro-
gen receptor-positive (ER+ ) tumors. amoxi en,
a selective ER modulator, reduces recurrence and
contralateral disease (side e ects include increased
risk o endometrial cancer, thromboembolism, and
stroke). Adjuvant therapy with tamoxi en has been
shown to lead to signi cant prolongation o disease-
ree and overall survival in ER+ disease, regardless
o nodal status. Anastrazole is an aromatase inhibi-
tor that may be used in patients with contraindica-
tions to tamoxi en, and only in post-menopausal
women, as they do not produce suf cient estrogen
opposition in pre-menopausal women. rastuzumab
is a monoclonal HER2 antibody that may be used as
adjuvant therapy in both pre- and post-menopausal
women who have overexpression o the HER2/neu
gene.
Stage is the best indicator o prognosis. When
limited to the breast only, there is a 99% cure rate,
however, 5-year survival decreases to 66%87%
based on Surveillance, Epidemiology, and End
Results (SEER) data with axillary spread. T e tumor,
node, metastasis ( NM) model is the most widely
accepted staging method. 0 implies no evidence
o a primary tumor and it includes in-situ lesions,
1 is a mass 2 cm, 2 is a mass rom 25 cm, 3
is a mass > 5 cm, and 4 is a mass with chest wall
invasion, skin edema or ulceration, or in ammatory
breast cancer.
194 G EN ERAL S U RG ERY EXAM I N ATIO N AN D BO ARD REVI EW
N0 implies negative lymph nodes, N1 means posi-
tive mobile ipsilateral axillary lymph nodes, N2 is xed
or matted ipsilateral axillary nodes, and N3 is ipsilat-
eral in raclavicular, supraclavicular, or internal mam-
mary nodes. T ere is also pathologic N-staging, based
upon number o histologically positive lymph nodes.
M0 disease implies no metastatic disease, and M1
means metastatic disease is present. T e most com-
mon locations or breast cancer metastasis are bone,
lung, and brain.
5. C. Injury to the intercostobrachial nerve, the lateral
cutaneous branch o the second intercostal nerve,
results in numbness o the medial upper arm.
T e anatomic borders o the breast are the second
rib superiorly, sixth to seventh rib in eriorly, sternal
border medially, and midaxillary line laterally. T e
parenchyma o the breast is comprised o glandular
lobes in a radial pattern, each with a ductal system
ending at the nipple, and a surrounding connective
tissue ramework made by the suspensory ligaments
o Cooper. T e most common distribution o cancer
is the upper outer quadrant (45%), ollowed by sub-
areolar (25%), upper inner (15%), lower outer (10%),
and lower inner (5%).
T e blood supply o the breast includes per o-
rator branches rom the internal mammary artery,
branches rom the posterior intercostal arteries,
and axillary artery branches including the lateral
thoracic and pectoral branches o the thoracoacro-
mial artery. Venous drainage parallels the arterial
supply. T e axillary lymph nodes drain 75% to 85%
o lymph rom the breast, with the remainder drain-
ing to parasternal/internal mammary lymph nodes.
T ere are three levels o lymph nodes: level I (lateral
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to pectoralis minor), level II (deep to pectoralis
minor), and level III (medial to pectoralis minor).
Nerves present in the axillary at pad, and to be
mind ul o during dissection, include the long tho-
racic nerve (innervating the serratus anterior, with
injury resulting in a winged scapula), the thora-
codorsal nerve (innervating the latissimus dorsi,
with injury resulting in weak adduction and inter-
nal rotation), the intercostobrachial nerve (provid-
ing sensation to the upper inner arm, with injury
resulting in parasthesias or numbness), and the
medial and lateral anterior thoracic nerves (inner-
vating the pectoralis muscles, with injury resulting
in weakness).
BIBLIOGRAPHY
American College o Radiology. Practice guideline or the
breast conservation therapy in the management o inva-
sive breast carcinoma. J Am Coll Surg. 2007;205(2):36276.
Bao , Prowell , Stearns V. Chemoprevention o breast can-
cer: tamoxi en, raloxi ene, and beyond. Am J T er. 2006;
13(4):33748.
Bartella L, Smith CS, Dershaw DD, et al. Imaging breast can-
cer. Radiol Clin North Am. 2007;45(1):4567.
Chan K, Morris GJ. Chemoprevention o breast cancer or
women at high risk. Semin Oncol. 2006;33(6):6426.
Giuliano AE, Hunt KK, Ballman KV, et al. Axillary dissection
vs no axillary dissection in women with invasive breast
cancer and sentinel node metastasis: a randomized clinical
trial. JAMA. 2011;305(6):569575.
King A, Morrow M. Breast Disease. In: Mulholland MW,
Lillemoe KD, Doherty GM, et al. eds. Greenf elds Surgery:
Scientif c Principles and Practice. 5th ed. Philadelphia, PA:
Lippincot, Williams & Wilins: 2011:26352701.
Patel RR, Sharma CG, Jordan VC. Optimizing the antihor-
monal treatment and prevention o breast cancer. Breast
Cancer. 2007;14(2):11322.
 55
Ductal Carcinoma in Situ
Angela Penn
A 42-year-old woman presents with extensive new cal-
ci cations on screening mammography. She undergoes
stereotactic core biopsy that reveals ductal carcinoma in
situ (DCIS), intermediate grade, with comedonecrosis.
Estrogen receptor status is positive (ER+). She has no
signi cant past medical history and there is no amily
history o cancer.
1. Which of the following is a risk factor for this patient
actually having occult invasion instead of DCIS?
A. + ER receptor status
B. Palpable mass on clinical exam
C. DCIS that spans a diameter larger than 3 cm
D. intermediate grade histology
E. Contralateral disease
2. Which of the following statements is true?
A. For patients undergoing breast conservation
therapy (BC ) or DCIS, the optimal margin
width is 10 mm.
B. Adjuvant radiation does not decrease the risk o
recurrence a er lumpectomy or DCIS.
C. Adjuvant radiation increases survival in patients
undergoing BC or DCIS.
D. Risk o death a er any treatment or DCIS is less
than 2% a er ten years, and is usually secondary
to recurrence as invasive disease.
E. Approximately 10% o ipsilateral breast recur-
rences a er lumpectomy alone or in conjunction
with radiation are invasive disease.
3. Regarding the role of sentinel lymph node biopsy
(SLNB) in DCIS, which of the following statements
is true?
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A. SLNB does not need to be per ormed i this
patient undergoes a mastectomy or her DCIS.
B. By de nition, DCIS is noninvasive disease, there-
ore SLNB should never be per ormed.
C. SLNB has an almost negligible risk o lymph-
edema.
D. SLNB should be considered at the time o
lumpectomy or DCIS located in the axillary tail
o the breast.
E. SLNB should only be considered i a patient has
DCIS in the setting o a mass.
4. Regarding imaging in DCIS, which of the following
is true?
A. Approximately 50% o all mammography
detected breast cancers are DCIS.
B. MRI estimates o the size and extent o DCIS
o en correlate with pathologic evaluation.
C. DCIS o en extends beyond the area o calci ca-
tion seen on mammography.
D. Magnetic resonance imaging (MRI) is better
than mammography or distinguishing DCIS
rom benign, atypical proli erative lesions or
microinvasion.
E. MRI is not help ul in identi ying multicentric
disease and synchronous disease in the contra-
lateral breast.
5. With regard to adjuvant tamoxifen for DCIS,
which of the following statements is true?
A. amoxi en ( MX) improves both local recur-
rence and survival rates in DCIS.
196 G EN ERAL S U RG ERY EXAM I N ATI O N AN D BO ARD REVI EW
B. MX has no signi cant e ect on survival in
invasive breast cancer.
C. Side e ects o MX includes an increased risk o
ovarian cancer.
D. amoxi en is equally e ective in ER+ lesions as
in ER lesions.
E. In women undergoing breast conservation
therapy or DCIS, MX decreases invasive and
non-invasive breast cancer events or both the
ipsilateral and contralateral breast.
ANSWERS
1. B. Because o sampling error, a ter surgical exci-
sion o a lesion diagnosed on core biopsy, DCIS
is upgraded to invasive cancer in approximately
10% to 20%. Risk actors or occult invasive dis-
ease include presence o a mass, extent o DCIS
greater than 5 cm, comedonecrosis, or high grade
histology.
DCIS represents a heterogeneous spectrum o
disease involving the abnormal proli eration o
epithelial cells con ned to the breast ducts. Unlike
invasive cancer, DCIS is bounded by the basement
membranes and does not invade beyond its ductal
origin or into the neighboring tissues. Although
studies o the natural progression o DCIS are lack-
ing, the general consensus is that in situ disease
represents an intermediary between normal breast
tissue and invasive disease. However, its behavior
is highly variable, ranging rom indolent low-grade
lesions that may never progress to invasion, to high-
grade lesions that may harbor oci o invasive cancer.
T is non-obligate progression and variation in bio-
logic behavior has raised dilemmas in clinical man-
agement with some patients being over treated or
the disease.
2. D. T e mortality or patients with DCIS a er
excision is low (less than 2% in 10 years based on
population studies) but is generally secondary to
recurrence as invasive disease. Almost hal the recur-
rences a er treatment or DCIS occur in the orm o
invasive disease. T ere ore, the undamental goals
o management are to prevent recurrence and to
minimize treatment related morbidity. DCIS can be
treated by either mastectomy or breast conservation
therapy (BC ). Mastectomy should be considered
in patients with extensive or multicentric disease, in
patients in whom the breast volume to tumor vol-
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ume ratio is low and lumpectomy with reasonable
cosmesis cannot be achieved, or in patients in whom
lumpectomy ails to achieve negative margins. Most
patients, however, can and should be considered or
BC .
Optimal margins or lumpectomy remain contro-
versial. Studies suggest a decrease in recurrence rates
a er lumpectomy alone with increased margin width
up to 10 mm with no additional bene t to margins
wider than 10 mm. However, this bene t is eradi-
cated when radiation is added to lumpectomy and
the general consensus is that margin width greater
than or equal to 2 mm is adequate with some advo-
cating absence o cancer at the inked margin as the
de nition o a negative margin.
Given the variable behavior o DCIS, there have
been extensive e orts to identi y a subgroup o
patients with indolent disease or whom radiation
can be sa ely eliminated a er lumpectomy. Such
e orts have thus ar resulted in con icting data.
T ere ore, radiotherapy remains standard o care or
patient with DCIS who undergo BC . T e prospec-
tive National Surgical Adjuvant Breast and Bowel
project (NSABP) B-06 trial demonstrated signi cant
decreases in recurrence rate with adjuvant radiation
in BC or invasive disease. T ere were some women
in this study who were initially thought to have inva-
sive disease. However, upon review o their biopsy
specimens, they were determined to have DCIS
instead.
T ese women were ound to have a signi cant
reduction in recurrence rates, including recur-
rence as invasive disease. T e NSABP B-17 study
was subsequently designed to evaluate radiother-
apy speci cally in patients with DCIS. T is study
ound a signi cant reduction in recurrence rates
with adjuvant radiation or noninvasive disease.
In neither invasive nor in situ disease was there a
demonstrated survival bene t to adjuvant radio-
therapy. T e European Organisation or Research
and reatment o Cancer (EOR C) 10753 trial was
a large European study that corroborated similar
ndings.
3. D. Although by de nition DCIS is non-invasive
disease, given the signi cant chance o upgrading
to invasive disease a er surgical excision, sentinel
lymph node biopsy to evaluate or possible nodal
metastases has been advocated in certain scenar-
ios. Although it is reasonable to consider SLNB in

patients who have risk actors or occult invasive
disease to avoid a second operation should they be
upgraded to invasive disease a er excision, many
patients would undergo unnecessary axillary sam-
pling. SLNB is not entirely benign and there is about
a 6% risk o lymphedema. Since SLNB can be per-
ormed subsequent to a lumpectomy, SLNB is not
advocated at the time o initial excision or most
patients. T e general consensus, however, is to per-
orm a SLNB i a patient is to undergo mastectomy
or DCIS. In this situation, removal o the breast
precludes subsequent SLNB should the nal pathol-
ogy reveal invasive disease. T ese patients would
then require axillary lymph node dissection. For
the same reason, patients whose DCIS is located in
the axillary tail o the breast should be considered
or SLNB at the time o initial excision as lymphatic
drainage to the axilla may be disrupted during exci-
sion and may decrease the likelihood o success ul
localization o a SLN subsequently. Most patients,
however, can and should undergo SLNB subsequent
to a nal pathological determination o invasive
disease.
4. C. Most cases o DCIS are discovered upon
screening mammography and DCIS now accounts
or approximately 20% o all screening detected
breast cancers. DCIS most o ten presents mam-
mographically as microcalci ications, sometimes
with branching corresponding to intraductal
disease.
Mammography is limited in that DCIS o en
extends beyond the area o microcalci cations seen
on imaging. T us, up to (15% to 20%) o women
undergoing lumpectomy or DCIS may be subjected
to re-excision to obtain negative margins. In addi-
tion, up to 40% o DCIS lesions grow discontinu-
ously which can make complete excision dif cult.
T is is a postulated reason as to why adjuvant breast
irradiation is e ective in decreasing recurrence rates
a er excision.
Given the limitations o mammography, MRI has
been studied as an alternate imaging modality. MRI
tends to have high sensitivity but low speci city in
breast cancer imaging. Given its high sensitivity, it
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C H AP TER 5 5 D U C TAL C ARC I N O MA IN S I TU 197
may be help ul in identi ying multicentric or syn-
chronous disease in the contralateral breast. How-
ever, it appears to be no better than mammography
or distinguishing DCIS rom benign proli erative
lesions and MRI estimates o lesion size and extent
correlate only moderately well with pathological
ndings, both over and underestimating the size o
the DCIS.
5. E. Given the role o estrogen in the pathogen-
esis o breast cancer, strategies targeting the estro-
gen pathway have been investigated as possible
adjuncts to breast cancer therapy. amoxi en is a
selective estrogen receptor modulator (SERM).
While it is an estrogen receptor agonist at some
sites such as the bone and endometrium, it has
potent antagonist e ects in breast tissue. Stud-
ies had demonstrated the bene t o tamoxi en as
adjuvant therapy in invasive disease, including
decreased local recurrence and breast cancer mor-
tality rates. T e NSABP B-24 study was designed
to investigate tamoxi en in the setting o DCIS.
In this study, patients undergoing lumpectomy
and radiation or DCIS were subsequently rand-
omized to receive tamoxi en or placebo. amoxi en
was administered in the treatment group at 10 mg
twice a day or 5 years. T e median ollowup was
74 months and patients in the tamoxi en arm had
37% ewer breast cancer events overall and there
was both an ipsilateral and contralateral breast
bene t. T ere was no bene t in terms o overall
survival. Adverse e ects o tamoxi en include an
increased incidence o thromboembolic events and
endometrial cancer. A subsequent subset analysis
demonstrated that the bene t o tamoxi en was
limited to those with ER-positive disease.
DCIS represents a very heterogenous group o
lesions that have a variable clinical course lend-
ing challenges to the management o this disease.
Almost all patients with DCIS will be cured o the
disease and adjuvant radiation and endocrine ther-
apy have urther improved recurrence rates. With
urther understanding o the biology o the subtypes
o DCIS, we will be able to better tailor therapy to
individual patients.
198 G EN ERAL S U RG ERY EXAM I N ATIO N AN D BO ARD REVI EW

DCIS
Non-obligate precursor to invasive cancer.
O en diagnosed with mammography as
microcalci cations.
Usually unilateral but multi ocality is common.
Surgical treatment is with lumpectomy or
mastectomy.
Adjuvant radiotherapy is indicated i treated
with lumpectomy.
LCIS
Risk actor or invasive cancer, both lobular and ductal. Risk is
elevated or both the ipsilateral and contralateral breast. Consider
hormone modulators to decrease risk.
O en mammographically occult and ound incidentally on biopsy or
other reasons. Consider MRI.
O en bilateral and multi ocal.
Surgical excision is indicated i ound on core needle biopsy sec-
ondary to risk o sampling error (DCIS or invasive cancer nearby is
requently ound). I ound on surgical excision, no urther excision
necessary since it is not treated as a precursor lesion.
No adjuvant radiotherapy.

BIBLIOGRAPHY Fisher B, Constantino JP, Wickerham DL, et al. amoxi en

Allred DC, Anderson SJ, Paik S, et al. Adjuvant tamoxi en
reduces subsequent breast cancer in women with estrogen
receptor-positive ductal carcinoma in situ: a study based
in NSABP Protocol B-24. J Clin Oncol. 2012;30:126873.
Bijker N, Meijnen P, Peterse JL, et al. Breast-conserving treat-
ment with or without radiotherapy in ductal carcinoma
in situ: en-year results o European Organisation or
Research and reatment o Cancer randomized phase III
trial 10853 a study by the EOR C Breast Cancer Coop-
erative Group and EOR C Radiotherapy Group. J Clin
Oncol. 2006;24:33817.
Burak WE Jr, Owens KE, ighe MB, et al. Vacuum-assisted
stereotactic breast biopsy: histologic underestimation o
malignant lesions. Arch Surg. 2000;135:7003.
Dunne C, Burke JP, Morrow M, et al. E ect o margin status
on local recurrence a er breast conservation and radia-
tion or ductal carcinoma in situ. J Clin Oncol. 2009;27:
161520.
Ernster VL, Barclay J, Kerlikowske K, et al. Mortality among
women with ductal carcinoma in situ o the breast in the
population-based Suveillance, Epidemiology and End
Results program. Arch Intern Med. 2000;160:9538.
Fisher B, Redmond C, Poisson R, et al. Eight-year results o a
randomized clinical trial comparing total mastectomy and
lumpectomy with or without irradiation in the treatment
o breast cancer. N Engl J Med. 1989;320:8228.
Fisher B, Dignam J, Wolmark N, et al. Lumpectomy and radia-
tion therapy or the treatment o intraductal breast can-
cer: Findings rom National Surgical Adjuvant Breast and
Bowel Project B-17. J Clin Oncol. 1998;16:44152.
Fisher B, Constantino JP, Remond C, et al. A random-
ized clinical trial evaluating tamoxi en in the treat-
ment o patients with node-negative breast cancer who
have estrogen-receptor-positive tumors. N Engl J Med.
1989;320:47984.
Fisher B, Dignam J, Wolmark N, et al. amoxi en in treatment
o intraductal breast cancer: National Surgical Adjuvant
Breast and Bowel Project B-24 randomized controlled
trial. Lancet. 1999;353:19932000.
or the prevention o breast cancer: Current status o the
National Surgical Adjuvant Breast and Bowel Project P-1
Study. J Natl Cancer Inst. 2005;97:165262.
Huo L, Sneige N, Hunt KK, et al. Predictors o invasion in
patients with core-needle biopsy-diagnosed ductal car-
cinoma in situ and recommendations or a selective
approach to sentinel lymph node biopsy in ductal carci-
noma in situ. Cancer. 2006;107:17608.
Hwang ES, Kinkel K, Esserman LJ, et al. Magnetic resonance
imaging in patients diagnosed with ductal carcinoma in
situ: value in the diagnosis o residual disease, occult inva-
sion, and multicentricity. Ann Surg Oncol. 2003;10:3818.
Kau mann M, Morrow M, von Minckwitz G, et al. Locore-
gional treatment o primary breast cancer: consensus rec-
ommendations rom an international expert panel. Cancer.
2010;116:118491.
Kerlikowske K, Molinaro A, Cha I, et al. Characteristics asso-
ciated with recurrence among women with ductal carci-
noma in situ treated by lumpectomy. J Natl Cancer Inst.
2003;95:16921702.
King A, Farr GH Jr, Cederbom GJ, et al. A mass on breast
imaging predicts coexisting invasive carcinoma in patients
with a core biopsy diagnosis o ductal carcinoma in situ.
Am Surg. 2001;67:90712.
MacDonald HR, Silverstein MJ, Mabry H, et al. Local
control in ductal carcinoma in situ treated by excision alone:
Incremental bene t o larger margins. Am J Surg. 2005;
190:5215.
McLaughlin SA, Wright MJ, Morris K , et al. Prevalence o
lymphedema in women with breast cancer 5 years a er
sentinel lymph node biopsy or axillary dissection: objec-
tive measurements. J Clin Oncol. 2008;26:52139.
Silverstein MJ, Lagios M, Groshen S, et al. T e in uence o
margin width on local control o ductal carcinoma in situ
o the breast. N Engl J Med. 1999;340:145561.
Vanderwalde LH, Dang CM, Bresee C, et al. Discordance
between pathologic and radiologic tumor size on breast
MRI may contribute to increased re-excision rates. Am
Surg. 2011;77:13613.

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 56
In ammatory Breast Cancer

Ranjna Sharma

A 42-year-old emale presents to your o ce with C. Modi ed radical mastectomy

an erythematous and edematous le breast that she
reports as occurring acutely over the past 2 weeks. She
is not breast- eeding. She denies any recent trauma or
source o in ection. She presented to her primary care
physician last week who administered a trial o antibi-
otics or presumed cellulitis, without any improvement
in symptoms. Upon your physical exam, you note an
erythematous, edematous, le breast with clinical nd-
ings o peau dorange and a mass underlying the area o
clinical change. T e le breast appears larger than the
right breast. You are able to appreciate ullness in the
le axilla. You order dedicated breast imaging. She has
a diagnostic mammogram per ormed that shows skin
thickening and trabecular distortion in the le breast,
with increased tissue density in the retroareolar region.
An ultrasound o the le breast showed a 6 cm vague
irregular mass in the retroareolar region, with two
enlarged le axillary lymph nodes. A skin punch biopsy is
per ormed in your o ce and it demonstrates cancer cells
in ltrating the dermal lymphatics. A core needle biopsy
o the mass reveals invasive ductal carcinoma. A ne
needle aspiration o an enlarged le axillary lymph node
shows metastases. Based on the clinical presentation,
imaging ndings, and histopathologic results, a diagnosis
o in ammatory breast cancer (IBC) is made. A staging
work-up is negative or any distant sites o disease. You
discuss the treatment modalities o surgery, chemotherapy,
and radiation therapy as part o her treatment plan.
1. What surgical procedure will this patient have?
A. Mastectomy
B. Mastectomy with sentinel lymph node biopsy
D. Radical mastectomy
2. What impact has the addition o neoadjuvant
chemotherapy had on the outcome o patients with
inf ammatory breast cancer?
A. It decreases the risk o developing a contralateral
breast cancer in the uture.
B. It decreases the risk o developing a concurrent
ovarian cancer.
C. It increases e ectiveness o endocrine therapy.
D. It improves survival.
3. What is the role o radiation therapy in this clinical
scenario?
A. Decreased incidence o local recurrence.
B. It improves response to endocrine therapy.
C. It improves response to chemotherapy.
D. It prevents distant metastases.
4. What is the usual order o treatments delivered?
A. Surgery, radiation therapy, chemotherapy
B. Radiation therapy, surgery, chemotherapy
C. Chemotherapy, surgery, radiation therapy
D. Radiation therapy, chemotherapy, surgery
5. What is the underlying pathophysiology in
inf ammatory breast cancer contributing to the
skin changes that are noted on clinical exam?
A. In ection (mastitis/abscess)
B. umor emboli obstructing the dermal lymphatic
vessels
C. Localized dermatitis

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200 G EN ERAL S U RG ERY EXAM IN ATI O N AN D BO ARD REVIEW
D. Congestive heart ailure causing skin edema
E. Concurrent non-Hodgkin Lymphoma
ANSWERS
1. C. T is patient will have a modi ed radical mas-
tectomy (MRM), which is comprised o a simple
mastectomy and axillary lymph node dissection.
T e borders o the mastectomy portion o the proce-
dure are superiorly to the clavicle and deltopectoral
groove, laterally to the latissimus muscle, in eriorly
to the upper edge o rectus sheath, and medially to
the sternal border. T e posterior border is the ascia
overlying the pectoralis major muscle. T e mastec-
tomy should resect any residual gross disease and
obtain negative surgical margins. T e surgical plan
must remove all skin changes. T e mastectomy skin
aps must be closed without tension. T e borders o
an axillary lymph node dissection are the axillary
vein superiorly, the pectoralis major muscle anteri-
orly, the subscapularis muscle posteriorly, the serra-
tus anterior muscle medially, and the latissimus dorsi
muscle laterally. Within these anatomic boundaries,
dissection will occur which will excise the Level 1
and Level 2 axillary lymph nodes.
In eriorly, the dissection should be carried out to
the 4th or 5th rib. T e Level 1 nodes are located lat-
eral to the pectoralis minor muscle and the Level 2
nodes are located posterior to this muscle. A modi-
ed radical mastectomy or a patient with IBC with
metastases to the axillary lymph nodes will remove
the a ected skin, generalized disease process in the
breast, and involved lymph nodes. T is will contrib-
ute to improved local control o the disease process.
A sentinel lymph node biopsy is not indicated since
there is already known disease in the axillary nodes.
Consequently, to control regional disease, a complete
axillary lymph node dissection must be done.
2. D. T e introduction o neoadjuvant chemother-
apy has signi cantly improved clinical outcomes in
patients with IBC. It is used to downstage the tumor
to allow surgical resection to be more success ul by
decreasing the likelihood o leaving residual dis-
ease behind. Anthracycline-based regimens show a
survival bene t. A regimen containing cyclophos-
phamide, 5- uorouracil, and either doxorubicin or
epirubicin is generally used. axanes are also admin-
istered. T e combination o anthracycline and taxane
regimens increases the rate o clinical response to
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chemotherapy and shows improvement in survival
and prognosis. I Her2/neu is overexpressed, then
trastuzumab is given or 1 year, which contributes
to increased pathologic complete response (pCR).
T e skin changes o erythema and edema in IBC
will generally improve when a patient is respond-
ing to neoadjuvant chemotherapy. I a pCR can be
achieved, survival is increased. T e improvement
in survival is seen in both disease- ree survival and
overall survival.
3. A. Radiation therapy is administered a er MRM,
thus it is post-mastectomy radiation therapy (PMR ).
PMR is given to improve local control o the dis-
ease process and decrease the risk o local recurrence
seen in patients with IBC due to high local disease
burden at the time o diagnosis. Administration o
PMR is known to decrease the risk o recurrence on
the chest wall, mastectomy scar, and regional lymph
node basins. It is delivered to the chest wall and
regional lymph node basins in the axilla, in raclavic-
ular, supraclavicular, and internal mammary regions
in standard ractionation, with a boost to the chest
wall scar. Any area with pretreatment skin involve-
ment should receive radiation to decrease the risk o
local recurrence.
4. C. IBC is treated with a multidisciplinary/multi-
modality approach, combining local and systemic
treatments. Local treatment modalities are surgery
and radiation therapy, whereas chemotherapy and
endocrine therapy are utilized as systemic therapies.
However, in regards to endocrine therapy, most IBCs
are ER/PR negative, so there would be no role or
endocrine therapy in those patients. T is combina-
tion and order o neoadjuvant chemotherapy, MRM,
and PMR will improve local disease control, thus
decreasing risk o local recurrence. MRM is most
e ective i a patient has a good clinical response
(decrease in skin erythema and edema) to neoadju-
vant chemotherapy, and particularly so in patients
who have a pathologic complete response (pCR)
to neoadjuvant chemotherapy. T is multimodality
treatment plan has improved survival, particularly
disease- ree survival.
5. B. In IBC, tumor emboli invade the dermal lym-
phatic vessels, causing an obstruction, which leads
to the edema, induration, and peau dorange appear-
ance. T e emboli invade vessels in the papillary and
reticular dermis.

BIBLIOGRAPHY
Dawood S, Merajver SD, Viens P, et al. International expert
panel on in ammatory breast cancer: consensus statement
or standardized diagnosis and treatment. Annals of Oncol-
ogy. 2011;22:51523.
Duskin H, Cristo anilli M. In ammatory Breast Cancer. J Natl
Compr Canc Netw. 2011;9:23341.
Khan AJ, Haf y BG. Postmastectomy Radiation T erapy. In:
Kuerer HM, ed. Kuerers Breast Surgical Oncology. New
York, NY: McGraw-Hill; 2010:9951008.
Li BD, Sicard MA, Ampil F, et al. rimodal therapy or In am-
matory Breast Cancer: A Surgeons Perspective. Oncology.
2010;79:312.
Makower D and Sparano JA. How Do I reat In ammatory
Breast Cancer? Current Treatment Options in Oncology.
2013;14:6674.
National Comprehensive Cancer Network Guidelines Version
2.2011 In ammatory Breast Cancer, IBC-1. NCCN breast
cancer clinical practice guidelines in oncology. Available
at: http://www.nccn.org/pro essionals/physician_gls/PDF/
breast.pd . Accessed June 1,2014.
Negron Gonzalez V, Oh JL, Cristo anilli M, Babiera GV.
In ammatory Breast Cancer. In: Kuerer HM, ed. Kuerers
http://surgerybook.net/
C H AP TER 5 6 I N f LAM M ATO RY BREAS T C AN C ER 2 01
Breast Surgical Oncology. New York, NY: McGraw-Hill;
2010:92736.
Neuman HB and Van Zee KJ. Axillary Lymph Node Dissec-
tion. In: Kuerer HM, ed. Kuerers Breast Surgical Oncology.
New York, NY: McGraw-Hill; 2010:67991.
Rao R and Leitch AM. Modi ed Radical Mastectomy and
echniques or Avoiding Skin Necrosis. In: Kuerer HM, ed.
Kuerers Breast Surgical Oncology. New York, NY: McGraw-
Hill; 2010:69397.
Recht A, Edge SB, Solin LJ, et al. Postmastectomy radiother-
apy: Guidelines o the American society o clinical oncol-
ogy. J Clin Oncol. 2001;19(5):153969.
Rehman S, Reddy CA, endulkar RD. Modern outcomes o
in ammatory breast cancer. Int J Radiation Oncol Biol
Phys. 2012;84(3):61924.
Robertson FM, Bony M, Yang, W, et al. In ammatory breast
cancer: T e disease, the biology, the treatment. CA Cancer
J Clin. 2010;60:35175.
Saigal K, Hurley J, akita C, et al. Risk actors or locoregional
ailure in patients with in ammatory breast cancer treated
with trimodality therapy. Clinical Breast Cancer. 2013;
13(5):33543.
Zellars R. Post-mastectomy radiotherapy. Clin Adv Hematol
Oncol. 2009;7(8):53343.
 57
Breast Reconstruction

Pamela C. Masella and Mark K. Markarian

A 42-year-old otherwise healthy emale recently under- 3. T e patient inquires about a nipple-sparing
went core-needle biopsy o a palpable 4 cm le breast mastectomy. Which of the following is a
mass in the upper outer quadrant that revealed inva- contraindication to this procedure?
sive ductal carcinoma. On physical exam she had no A. 3 cm tumor
urther palpable lesions and no palpable lymph nodes. B. Pagets disease
Metastatic work-up was negative. She would like to dis- C. A large tumor-to-areola distance
cuss mastectomy and reconstruction options prior to D. Positive axillary lymph nodes
her surgery. E. Multi ocal disease

1. Regarding breast reconstruction options, which of 4. T e patient undergoes skin-sparing mastectomy

the following is correct?
A. Autologous tissue reconstruction is pre erred
whenever possible over implant reconstruction.
B. I implant reconstruction is desired, tissue
expanders will be placed at the time o mas-
tectomy and nal implants will be placed 4 to
6 weeks later.
C. Reconstruction does not signi cantly inter ere
with the detection o recurrent disease.
D. Smoking is an absolute contraindication or
autologous tissue reconstruction.
E. Autologous and implant reconstruction can sig-
ni cantly delay subsequent adjuvant therapy.
2. Which of the following is an advantage of
autologous tissue reconstruction?
A. Better symmetry with the contralateral breast
B. Shorter operating time
C. Shorter inpatient hospitalization
D. Lower potential or the need o blood trans usion
when compared with implant reconstruction
E. No revisions needed
and sentinel lymph node biopsy with tissue
expander placement at the time of surgery.
Which of the following pathologic criteria
would preclude her from completing implant
reconstruction?
A. A negative sentinel lymph node biopsy
B. 3 cm primary tumor
C. 10 mm margins
D. Stage IIA
E. Stage IB
5. Intraoperatively, the patients sentinel lymph
node biopsy is positive for invasive ductal
carcinoma, she undergoes axillary dissection
and her final pathology returns p 2 pN1
MO, Stage IIB invasive ductal carcinoma. She
undergoes adjuvant chemotherapy and radiation
therapy to the chest wall, infraclavicular,
supraclavicular, and inframammary areas.
She may not be an appropriate candidate
for which of the following autologous tissue
reconstructions?

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 C H AP TER 5 7 BREAs T RECo n s TRu C Ti o n 203

De e p Infe rior Epiga s tric Pe rfora tor fla p

Fla p conne cte d to
re cipie nt blood ve s s e ls

Fla p with de e p infe rior

e piga s tric a rte ry & ve in
Ma s te ctomy
de fe ct

Re ctus a bdominis
mus cle

De e p infe rior
e piga s tric Incis ion
S ca r
a rte ry a nd ve in
Be fore Afte r
Alila Me dica l Me dia - www.Alila Me d ica lMe d ia .c om

Fre e TRAM Fla p S urge ry

Fla p conne cte d to
re cipie nt blood ve s s e ls

Fla p with
Ma s te ctomy blood ve s s e ls
de fe ct

Re ctus a bdominis
mus cle
Blood ve s s e ls Me s h

S ca r

Be fore Afte r
Alila Me dica l Me dia - www.Alila Me d ica lMe d ia .c om

La tis s imus Dors i Fla p

Alila Me dica l Me dia - www.Alila Me d ica lMe d ia .c om

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204 G En ERAL s u RG ERY EXAM i n ATi o n An D Bo ARD REVi EW

S upe rior Infe rior Epiga s tric Arte ry Fla p

Fla p conne cte d to
re cipie nt blood ve s s e ls

Ma s te ctomy
de fe ct

Re ctus a bdominis
mus cle
De e p infe rior
e piga s tric
a rte ry a nd ve in
Fla p with s upe rficia l S ca r
S upe rficia l infe rior infe rior e piga s tric
e piga s tric a rte ry a nd ve in a rte ry a nd ve in
Be fore Afte r
Alila Me dica l Me dia - www.Alila Me d ica lMe d ia .c om

Tra nsve rs e Re ctus Abdominis Myocuta ne ous (TRAM) Fla p S urge ry

Ma s te ctomy Fla p configure d to

de fe ct form bre a s t mound

Re ctus a bdominis
mus cle
Me s h
Blood ve s s e ls

S ca r

Be fore TRAM fla p pa s s e d Afte r

unde r s kin to che s t
Alila Me dica l Me dia - www.Alila Me d ic a lMe d ia .c om

A. Pedicled transverse rectus abdominis myocuta-
neous ( RAM) ap
B. Free transverse rectus abdominis myocutaneous
( RAM) ap
C. Latissimus dorsi ap
D. Deep in erior epigastric per orator (DIEP) ap
E. Super cial in erior epigastric artery (SIEA) ap
ANSWERS
1. C. Autologous or synthetic breast reconstruction
has not been shown to decrease the ability to detect
local or locoregional breast cancer recurrence. Mul-
tiple studies have shown that reconstruction a er
mastectomy with a variety o methods does not
adversely af ect the incidence or time to detection
o recurrent breast cancer. T ere is debate about
whether breast reconstruction delays time to adju-
vant therapy, primarily surrounding autologous
reconstruction due to increase in post-operative
wound complications, however, this does not appear
to be signi cant enough to af ect cancer-speci c sur-
vival.
Additionally, immediate breast reconstruction o
any variety is associated with decreased breast can-
cer-speci c mortality, particularly among younger
women. Patient pre erence, and li estyle, the avail-
ability o autologous tissue, and plans or adjuvant
cancer therapies are variables that can in uence the
timing and choice o operative technique. While
heavy smoking is not an absolute contraindication
or autologous tissue reconstruction, it does in u-
ence/limit the type o autologous tissue options that
are available.

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A er placement o tissue expanders, rst expan-
sion is typically approximately 14 days rom the ini-
tial surgery. issues may be expanded up to 25% more
than the desired volume over a variable amount o
time, a er which the breast tissue is allowed to rest,
on average, or 2 to 4 weeks, be ore tissue expand-
ers are exchanged with permanent breast implants.
T e overall time to complete the expansion process
is typically 3 to 6 months depending on the desired
breast size, the thickness o the mastectomy aps, and
the patients ability to tolerate the expansion.
2. A. Autologous tissue reconstruction involves the
trans er o vascularized muscle, skin, and subcuta-
neous tissue to the mastectomy de ect. issue can
be trans erred on a vascular pedicle or as a ree ap
requiring a microsurgical anastomosis. T is method
typically allows or a more natural appearing breast
contour, with a so er texture than implant recon-
struction and o entimes eliminates the need or
contralateral symmetry procedures. Autologous
reconstruction is also associated with ewer revi-
sion surgeries. Disadvantages include longer opera-
tive times, prolonged inpatient recovery time, higher
need or blood trans usion, morbidity associated
with the donor site and in the case o ree aps*, the
increased potential or total ap loss. (*Note: total
f ap loss may occur with any autologous reconstruc-
tionpedicled or ree.)
3. B. T e literature suggests that the nipple-sparing
mastectomy is oncologically sa e with a clearly
de ned set o pathologic parameters. Contraindica-
tions to nipple-sparing mastectomy include tumors
4.5 cm or greater, tumors located less than 2.5 cm
rom the areolar edge or less than 4 cm rom the nip-
ple center, gross involvement o the nipple-areola
complex including bloody nipple discharge or Paget
disease. umors that are multicentric, multi ocal, or
contain extensive ductal carcinoma in situ (DCIS)
remain eligible or nipple-sparing mastectomy. Addi-
tionally, women who have undergone neoadjuvant
therapy and subsequently meet the criteria or tumor
size and location can also be considered, but in am-
matory breast cancer is absolutely excluded. T e
presence o clinically positive axillary lymph nodes
is not a contraindication.
4. E. In general, women who have or will undergo
radiation therapy are not ideal candidates or pros-
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C H AP TER 5 7 BREAs T RECo n s TRu C Ti o n 205
thetic reconstruction because o decreased local
vascularity, the increased incidence o capsular con-
tracture, and the increased risk o surgical site in ec-
tion. T e indications or radiation therapy in breast
cancer according to the 2014 NCCN guidelines on
invasive breast cancer include those patients under-
going breast conservation therapy, tumors > 5 cm,
those with positive axillary lymph nodes, or positive
(< 1 mm) surgical margins. According to the AJCC
NM classi cation, a tumor > 5 cm is considered a
3 lesion while any lymph node involvement is at
least N1. Stage IIA ( 2 N0 M0) disease does not indi-
cate the need or radiation therapy. Stage IB includes
0-1, N1 M0 lesions and there ore may require radi-
ation therapy.
5. C. Because the patient underwent axillary dissection
and locoregional radiation therapy to the chest wall
and axilla, vessels in the area may have been damaged
during treatment. T e latissimus dorsi myocutane-
ous ap receives its primary blood supply rom the
thoracodorsal vessels, which may be compromised
during an axillary dissection or locoregional radia-
tion. T e primary blood supply to the RAM ap
are the superior epigastric vessels, while the primary
blood supply to the DIEP ap is rom deep in erior
epigastric per orators, and the super cial in erior
epigastric artery provides the primary blood supply
to the SIEA ap.
BIBLIOGRAPHY
Bezuhly M, emple C, Sigurdson LJ, et al. Immediate post
mastectomy reconstruction is associated with improved
breast cancer-speci c survival: Evidence and new chal-
lenges rom the Surveillance, Epidemiology, and End
Results database. Cancer. 2009;115(20):464854.
Craigie JE, Allen RJ, Dellacroce FJ, et al. Autogenous breast
reconstruction with the deep in erior epigastric per orator
ap. Clin Plast Surg. 2003;30:35969.
Gucwa A, Harper JG, Lind DS. Section 3: Breast, Skin, and
So issue. Chapter 5: Breast Procedures. In: Ashley SW.
ACS Surgery [Online]. Philadelphia, PA: Decker Intellectual
Properties; 2009.
Kronowitz SJ, Kuerer HM. Advances and surgical decision-
making or breast reconstruction. Cancer. 2006;107:893
907.
Kwon DS, Kelly CM, Ching CD. Invasive Breast Cancer. In:
Feig BW, Ching CD. MD Anderson Surgical Oncology
Handbook [Kindle Edition]. 5th ed. Philadelphia, PA: Lip-
pincott Williams & Wilkins; 2012.
Namnoum JD. Breast Reconstruction: RAM Flap ech-
niques. In: T ome, Charles H. Grabb and Smiths Plastic
206 G En ERAL s u RG ERY EXAM i n ATi o n An D Bo ARD REVi EW

Surgery. 6th ed. Philadelphia, PA: Lippincott Williams &
Wilkins; 2007:6417.
Nahabedian MY. Breast Reconstruction a er mastectomy:
Indications, technique, and results. In: Cameron JL, Cam-
eron AM. Current Surgical T erapy [Online]: Expert Con-
sult. 10th ed. Philadelphia, PA: Elsevier Health Sciences;
2011.
Reddy S, Colakoglu S, Curtis MS, et al. Breast cancer recur-
rence ollowing post mastectomy reconstruction com-
pared to mastectomy with no reconstruction. Ann Plast
Surg. 2011;66(5):46671.
Rozen WM, Ashton MW. Improving outcomes in autolo-
gous breast reconstruction. Aesthetic Plast Surg. 2008;33:
32735.

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Endo c r ine Sur ger y/Hea d a nd
Nec k Tumo r s
Robert B. Lim and Richard Smith

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 58
Adrenal Gland umors
Yong Choi
A 35-year-old emale presents with a 3 cm mass in
the le adrenal gland that was incidentally ound
on a computed tomography (C ) scan done or di -
use abdominal pain. T e patient reports intermittent
increases in blood pressure but she does not take any
anti-hypertensive medications. She has no other com-
plaints. She has no signi cant past medical history and
her only past surgery is a laparoscopic appendectomy
15 years ago. She does have a sister who had a total
thyroidectomy or medullary carcinoma o the thyroid
gland. She is re erred to the general surgery clinic by
her primary care physician or evaluation o this le
adrenal gland.
1. Regarding the workup of this adrenal mass, which
of the following is correct?
A. Diagnosis o Cushings syndrome is suggested
by suppression o plasma cortisol levels a er an
overnight low-dose dexamethasone test.
B. Patients with primary cortisol producing adeno-
mas have elevated cortisol levels and low plasma
adrenocorticotropic hormone (AC H).
C. T e risk o adrenal carcinoma is increased due to
the size o this adrenal mass.
D. Percutaneous biopsy o this mass is critical in
making the diagnosis.
2. Due to the history of intermittent hypertension,
the patient is evaluated for a pheochromocytoma.
Which of the following is correct?
A. Plasma- ree metanephrine levels but not
normetanephrine levels are sensitive markers or
pheochromocytoma.
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B. Monoamine oxidase inhibitors (MAOIs) can
alsely elevate plasma ree metanephrine and
normetanephrine levels.
C. Pheochromocytoma on a C scan is repre-
sented by venous phase enhancement exclu-
sively.
D. Pheochromocytomas represent the majority o
incidentalomas ound on C scan.
3. In relation to perioperative considerations
in patients with adrenal tumors, which of the
following is true?
A. In patients with pheochromocytoma, beta block-
ade should be initiated prior to alpha-adrenergic
blockade.
B. umor manipulation may stimulate sudden cat-
echolamine release during the surgery.
C. Patients with an aldosterone secreting adrenal
tumor will most likely have hyperkalemia.
D. Patients with cortisol producing tumor should not
receive heparin due to their hypocoagulability.
4. Which of the following is correct regarding the
natural history/treatment of the adrenal mass in
this patient?
A. Due to the size o the mass (3 cm), the patient
should be taken or an adrenalectomy even i the
mass is non- unctional.
B. Since the patient has a amily history o med-
ullary carcinoma o the thyroid, she should be
taken or an adrenalectomy.
C. Metastatic cancer presenting as a true adrenal
incidentaloma is common.
210 G EN ERAL S U RG ERY EXAM IN ATIO N AN D BO ARD REVI EW
D. T is patient can be ollowed with serial C scans
since malignancy at 3 cm is uncommon.
5. Which of the following statements on operative
treatment/technique is correct?
A. T e right adrenal vein is identi ed as it enters
directly into the vena cava.
B. Laparoscopic adrenalectomy should not be per-
ormed i the patient has adrenal carcinoma.
C. For benign disease, laparoscopic adrenalectomy
is clearly superior over the open adrenalectomy.
D. Posterior retroperitoneal approach has a higher
risk o injury to the liver and spleen compared to
the transabdominal approach.
ANSWERS
1. B. T e diagnosis o Cushings syndrome can be
accomplished by a dexamethasone suppression test.
Patients with Cushings syndrome ail to suppress
plasma cortisol levels a er an overnight low-dose
dexamethasone suppression test. In addition, these
patients have an elevated 24-hr urine ree cortisol level.
Once diagnosis o Cushings syndrome is con rmed,
urther tests can be per ormed to identi y the cause.
Patients with primary cortisol producing adeno-
mas have elevated cortisol levels and a low AC H
level. In addition, these patients should have a C
scan or MRI nding o an adrenal mass. Approxi-
mately 20% o patients with Cushings syndrome are
due to a cortisol producing adenoma. T e signs and
symptoms o Cushings syndrome include weight
gain, hypertension, diabetes mellitus, and centrip-
etal obesity. Other causes o Cushings syndrome
are aldosteronomas and adrenocortical carcinomas,
although these are rare.
T is patients adrenal mass is 3 cm in size. Adrenal
cortical carcinoma should be suspected with adrenal
masses greater than 6 cm. T e risk o a 3 cm adrenal
mass being a carcinoma is very low.
Percutaneous biopsy o an adrenal mass is not
commonly per ormed. One indication or a percu-
taneous biopsy is obtaining tissue diagnosis prior
to initiating treatment on a patient who has adrenal
metastasis on imaging. Biopsy should not be per-
ormed on patients suspected to have pheochro-
mocytoma due to the possibility o precipitating a
hypertensive crisis. As a rule, percutaneous biopsy
has a minimal role in the diagnosis o an adrenal
mass.
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2. B. Pheochromocytoma evaluation is necessary in all
patients with an adrenal mass, even i they have no
signs or symptoms o tachycardia, severe hyperten-
sion, cardiac palpitations, arrhythmias, anxiety, and
sweating. Plasma- ree metanephrine and norme-
tanephrine levels are sensitive markers or pheochro-
mocytoma and are easier to obtain than a 24-hour
urine collection. T e plasma- ree metanephrine and
normetanephrine levels should be 3 to 4 times the
normal in patients with pheochromocytoma.
Some medications can alsely elevate plasma- ree
metanephrine and normetanephrine levels. T ese
include MAOIs, tricyclic antidepressants, decongest-
ants, amphetamines, and phenoxybenzamine. I pos-
sible, these medications should be discontinued prior
to testing or pheochromocytoma.
Pheochromocytomas are hypervascular and they
have intense enhancement on the arterial phase o the
C scan. T ey also have a slow washout on delayed
imaging. With non-contrast C scan, the density o
pheochromocytoma is similar to that seen in muscle.
T ey also represent a small percentage o all inciden-
talomas ound on C scan, comprising 0% to 11%.
Non- unctioning adrenal adenomas are the most com-
mon incidentalomas ound on C scan examinations.
3. B. All patients with a diagnosis o pheochromocy-
toma should undergo alpha-adrenergic blockade. T is
should be initiated approximately 1 to 2 weeks be ore
surgery. Alpha blockade should help with blood pres-
sure control and control o intraoperative arrhyth-
mias. A er initiation o alpha blockade, beta-blockers
can be used in patients with persistent tachycardia or
hypertension. Some side e ects o alpha blockers are
atigue, loose stools, dizziness, and somnolence.
During the surgery or pheochromocytoma, care-
ul dissection o the adrenal gland must be per ormed
due to the act that tumor manipulation may cause a
sudden release o catecholamines. T is may result in
a sharp increase in blood pressure and bleeding rom
the small vessels. Immediate cessation o manipu-
lation o the adrenal gland will help normalize the
blood pressure. Good communication with the anes-
thesiologist throughout the procedure is necessary.
Patients with an aldosterone secreting adrenal
tumor have hypokalemia. T e aldosterone causes
the distal renal tubules to increase sodium and water
resorption and thereby increasing the potassium loss,
resulting in hypokalemia. Hypokalemia is associated
with increased risk o arrhythmias. T ere ore, oral

and intravenous supplementation should be given to
correct the hypokalemia.
Patients with cortisol producing tumors are
hypercoagulable due to the hyperhomocysteinemia,
increased clotting actors, impaired brinolysis, and
abnormalities in von-Willebrand actor. T ere ore,
these patients should be considered or pre-operative
heparin injection to decrease the risk o venous
thromboembolic events.
4. D. Adrenocortical carcinoma is not common and
the requency ranges rom 1.2% to 12% o all inciden-
talomas ound on C scan. Carcinoma is rare or an
adrenal mass size o less than 4 cm. Malignant trans-
ormation should be considered i a mass enlarges by
1 to 2 cm over 1 to 3 years. Since this patient has an
adrenal mass o 3 cm, it can be ollowed by serial C
scans i the mass is non- unctional.
With a amily history o medullary carcinoma o
the thyroid, multiple endocrine neoplasia (MEN)
syndrome must be considered. However, i the
patient has a non- unctioning adrenal adenoma and
workup or pheochromocytoma is negative, there is
no need to per orm an adrenalectomy in a 3 cm adre-
nal mass.
Metastatic cancer presenting as a true adrenal inci-
dentaloma is extremely rare. In a study by Lee et al.
only 0.2% o patients had unknown primary cancer
presenting as an adrenal mass. All o these patients
had tumor sizes greater than or equal to 6 cm.
5. A. T e anatomy o the right adrenal gland is di er-
ent than the le in that the adrenal vein enters directly
into the in erior vena cava (IVC). T ere ore, during the
operative approach, a plane is developed between
the lateral aspect o the IVC and the medial border o
the adrenal gland. T e vein is double clipped or stapled
with an Endo-GIA. On the le side, the adrenal vein
drains into the le renal vein.
T ere is no clear literature on the use o lapa-
roscopic adrenalectomy or adrenal carcinoma.
Reviews have been done that show the laparoscopic
approach to be equal to an open approach; and in a
NSQIP review o over 600 patients, the laparoscopic
approach was associated with shorter operations,
shorter hospital stays, less trans usions, ewer reop-
erations, and less 30 day mortality. However, the sur-
geon has to be aware o the possibility o invasion to
other structures. In cases o large adrenal cancers or
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C H AP TER 5 8 AD REN AL G LAN D TU M O RS 211
invasion, an open approach may be advisable. How-
ever, small lesions suspicious or carcinoma can be
per ormed by the laparoscopic approach.
As the technique o laparoscopic adrenalectomy
has grown in use, it is now considered a stand-
ard o care or small benign lesions. However, like
laparoscopic cholecystectomy, there have not been
randomized controlled trials comparing open to lap-
aroscopic adrenalectomy.
T ere are two basic approaches to laparoscopic
adrenalectomy: the transabdominal and the posterior
retroperitoneal. T e laparoscopic posterior retroperi-
toneal adrenalectomy has certain advantages over the
standard transabdominal approach. It eliminates the
need to retract the liver or the right side and
the spleen or the le side. It also reduces the risk o
injury to organs such as the liver and spleen. However,
patient selection is important and it can be technically
more demanding than the transabdominal approach.
BIBIOGRAPHY
Bickenbach KA, Strong VE. Laparoscopic transabdominal lat-
eral adrenalectomy. J of Surg Onco. 2012;106:61118.
Bittner JG, Brunt LM. Evaluation and management o adrenal
incidentaloma. J Surg Onco. 2012;106:55764.
Boland GW, Blake MA, Hahn PF, et al. Incidental adrenal
lesions: Principles, techniques, and algorithms or imaging
characterization. Radiology. 2008;249:75675.
Brunt LM, Moley JF. Adrenal incidentaloma. World J. Surg.
2001;25:90513.
Lee JE, Evans DB, Hickey RC, et al. Unknown primary can-
cer presenting as an adrenal mass: Frequency and implica-
tions or diagnostic evaluation o adrenal incidentalomas.
Surgery. 1998;124:111522.
Lee J, El- amer M, Schif ner , et al. Open and laparoscopic
adrenalectomy: Analysis o the National Surgical Qual-
ity Improvement Program. J AM Coll Surg. 2008;206(5):
9539.
Malayeri AA, Zaheer A, Fishman EK, et al. Adrenal masses:
Contemporary imaging characterization. J Comput Assist
Tomogr. 2013;37:52842.
Mansmann G, Lau J, Balk E, et al. T e clinically inappar-
ent adrenal mass: Update in diagnosis and management.
Endocr Rev. 2004;25:30940.
Phitayakorn R, McHenry, CR. Perioperative considerations
in patients with adrenal tumors. J Surg Onco. 2012;106:
60410.
askin HE, Siperstein A, Mercan S, et al. Laparoscopic poste-
rior retroperitoneal adrenalectomy. J Surg Onco. 2012;106:
61921.
erzolo M, Stigliano A, Chiodini I, et al. AME position state-
ment on adrenal incidentaloma. Euro J Endocrinology.
2011;164:85170.
 59
Hyperparathyroidism
Richard K. Inae
A 30-year-old emale is re erred to your general sur-
gery practice or evaluation or hypercalcemia by her
primary care physician. A chemistry panel per ormed
or her insurance a month ago shows an elevation o her
serum calcium levels. Her primary care physician reor-
dered the chemistry panel two days ago, which shows
a persistent calcium elevation but her urinalysis and
CBC are also normal. He is concerned she may have
primary hyperparathyroidism. T e patient states she
eels ne. Her past medical history is signi cant or a
kidney stone a couple o years ago. Her physical exam
is unremarkable.
1. You decide to check the patients parathyroid
hormone level. I the patient has primary
hyperparathyroidism, the parathyroid hormone
level would be:
A. Low
B. Normal
C. Elevated
D. A and B
E. B and C
2. T e patients parathyroid hormone level (P H)
and ollowing 24 hour urinary collection or
calcium and creatinine excretion con rm your
suspicion o primary hyperparathyroidism. You
obtain a sestamibi scan or preoperative planning
that shows a likely adenoma o the right lower
parathyroid gland. Your management o this
patient would be:
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A. Repeat observation and ollow up.
B. Bilateral neck exploration with identi cation o
all our parathyroid glands and subtotal resec-
tion o 3 glands.
C. Bilateral neck exploration with identi cation o
all our parathyroid glands and removal o the
abnormal parathyroid adenoma.
D. Bilateral neck exploration with identi cation o
all our parathyroid glands with total resection o
all our glands and reimplantation o a normal
gland in the sternocleidomastoid muscle.
3. During your parathyroidectomy or the above
patient, you are unable to locate the right lower
parathyroid gland despite nding the other three
normal appearing glands. T e next step would be:
A. Close up and repeat sestamibi scan.
B. Right thyroid lobectomy.
C. Explore the retroesophageal space.
D. Per orm a partial median sternotomy.
E. Selective venous sampling or parathyroid
hormone.
4. Af er per orming a total thyroidectomy in
a 55-year-old emale, the patient develops
Chvosteks sign and parasthesias on post-operative
day one. She is started on calcium and vitamin D
replacement therapy and discharged home with
those medications as well as teriparatide shots
(parathyroid hormone replacement therapy). Af er
 C H AP TER 5 9 H y P ERPARATH y Ro i d i s m 213

one year postsurgery, the patient still requires

calcium and vitamin D replacement as well as
teriparatide shots. T e likely structure injured
during the thyroidectomy was the:
A. Superior thyroid arteries
B. Middle thyroid veins
C. Recurrent laryngeal nerves
D. In erior thyroid arteries
E. Superior laryngeal nerves

ANSWERS
1. E. Hypercalcemia or high-normal serum calcium
levels with normal or elevated parathyroid hormone Sestamibi scan at 20 minutes post-injection shows normal
levels con rm primary hyperparathyroidism. Ele- appearing uptake in the thyroid gland and a nodular region
vated calcium levels should normally suppress P H o intense uptake in the in erior pole o the right lobe o the
production. Other associated lab ndings o primary thyroid gland. (Images and descriptions courtesy o Andrew
hyperparathyroidism may include decreased serum Mullins D.O. and John Yasmer M.D.)
phosphate levels, elevated serum chloride levels, and
elevated BUN, Cr, and alkaline phosphatase.
Primary hyperparathyroidism is usually ound
by routine lab testing, and most patients are asymp-
tomatic. I symptoms are present, they usually con-
sist o history o renal calculi, bone pain, pathologic
ractures, bone sha tumors, muscle weakness, and
depression/lethargy and body aches/pains.

2. C. A single parathyroid adenoma causes primary

hyperparathyroidism in 80% to 85% o cases. T e
rest o the cases are caused by parathyroid gland
hyperplasia (10%), double adenomas (4%), and para-
thyroid carcinoma (1%). Observation and medical
management is not cost e ective in the management
o primary hyperparathyroidism. T e resection o
the 3 parathyroid glands would be most applicable
to parathyroid gland hyperplasia.
A more recent alternative to the traditional
approach o bilateral neck exploration and our
gland identi cation is the removal o the parathyroid
adenoma using preoperative/intraoperative gamma-
probe localization with or without the use o intraop-
erative P H assay. T is approach (minimally invasive
radioguided parathyroidectomy or MIRP) relies on
the adenoma being seen on the technetium-99m ses-
tamibi (MIBI) scan which it does about 80% to 90%
o the time. I the MIBI scan is positive, then the long
term success rate o the MIRP (98%) is equivalent
to conventional our gland identi cation with the
bene ts o a signi cantly decreased hospital stay and
avoidance o general anesthesia.
Sestamibi scan at 2 hours post-injection shows normal wash-
out o the thyroid with a persistent increased uptake in the re-
gion o the in erior pole o the right lobe o the thyroid gland
which is consistent with a parathyroid adenoma. (Images
and descriptions courtesy o Andrew Mullins D.O. and John
Yasmer M.D.)
3. C. Surgical excision o the parathyroid adenoma is
curative o primary hyperparathyroidism in 90% to
97%. A missed parathyroid adenoma accounts or
the majority o surgical treatment ailures. Methods
described to acquire the missing parathyroid gland
via the transcervical incision include examining
the retroesophageal space, the carotid sheath, the
submandibular region, and the thymus gland. T e
most common location or a missing parathyroid
adenoma is the retroesophageal space. Additional
adjuncts include intraoperative ultrasound. Partial

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214 G EN ERAL s U RG ERy EXAm i N ATi o N AN d Bo ARd REVi EW
or complete thyroid lobectomy, bilateral internal
jugular vein sampling o P H to evaluate or which
side o the neck the adenoma is on, and partial or
complete median sternotomy are additional options
to consider. I the parathyroid gland is still missing,
a last approach is to ligate the in erior thyroid artery
and its arterial branches on the side o the missing
gland.
4. D. Most o the time, the in erior and superior para-
thyroid arteries are derived rom branches o o the
in erior thyroid artery. Another common variant is
the superior parathyroid arteries arising rom the
anastomosing branches o the superior and in erior
thyroid arteries.
BIBILIOGRAPHY
AACE/AAES ask Force on Primary Hyperparathyroidism.
T e American association o clinical endocrinologists and
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the American association o endocrine surgeons position
statement on the diagnosis and management o primary
hyperparathyroidism. Endocr Pract. 2005;11:4954.
Goldstein RA, Billheimer D, Martin WH, et al. Sestamibi
scanning and minimally invasive radioguided parathy-
roidectomy without intraoperative parathyroid hormone
measurement. Ann Surg. 2003 May; 237(5): 72231.
Goldstein RE, Blevins L, Delbeke D, et al. E ect o minimally
invasive radioguided parathyroidectomy on ef cacy, length
o stay, and costs in the management o primary hyper-
parathyroidism. Ann Surg. 2000;231:73242.
Halsted WS, Evans HM. T e parathyroid glandules: T eir
blood supply, and their preservation in operation upon the
thyroid gland. Ann Surg. 1907(46): 489506.
Heath DA, Heath EM. Conservative management o primary
hyperparathyroidism. J Bone Miner Res. 1991;6:S11720.
Jaskowiak N, Norton JA, et al. A prospective trial evaluating a
standard approach to reoperation or missed parathyroid
adenoma. Ann Surg.September 1996;224(3): 30820.
Udelsman R, Donovan PI. Remedial parathyroid surgery:
Changing trends in 130 consecutive cases. Ann Surg. Sep-
tember 2006;244(3): 4719.
 60
T yroid Disease

Richard K. Inae

A 43-year-old emale is re erred to your o ce by her cancer on FNA and no lymphadenopathy on

primary care physician or evaluation o a le thyroid ultrasound?
lesion. T e primary care physician thought the le A. Follow-up with repeat ultrasound in 6 months
side o the neck elt uller than the other and ordered B. Le thyroid lobectomy
an ultrasound o the neck and lab work. A lesion was C. Le thyroidectomy with isthmusectomy
seen on the ultrasound and her primary care physi- D. otal thyroidectomy
cian re erred her to general surgery or evaluation. T e
patient states that she eels per ectly well with no loss 4. What is the recommended initial surgical approach
in weight or hot ashes. She has no amily history o i the 1.1 cm lesion was non-diagnostic on initial
cancer or neck irradiation. A er per orming a thor- and repeat FNA, and no lymphadenopathy is seen,
ough physical exam, you eel a ullness in her le neck and the patient desires a limited surgical procedure?
corresponding with her le thyroid gland but no obvi- A. Repeat FNA again
ous discrete mass. Her lab work shows a normal chem- B. Le thyroid lobectomy
istry panel and normal thyroid panel. T e ultrasound C. Near-total thyroidectomy
reveals a 0.4 cm circular, smooth, solid, intracapsular D. otal thyroidectomy
lesion.
5. A 23-year-old Paci c Islander emale is re erred to
1. What would be your next step in management or you or evaluation or a lef neck mass. She rarely
this lesion? receives any medical care. She has noticed the neck
A. Fine-needle aspiration (FNA) mass or the past 6 months. T e lump is increasing
B. Repeat lab work in size with time. She states that otherwise, she
C. Observation eels normal. On physical exam, she has a palpable
D. Subtotal thyroidectomy lump on her lef thyroid gland as well as lef neck
lymphadenopathy. She is very thin with long limbs
2. What would your next step be i the lesion were and round, rm lumps in her lips. You suspect
1.1 cm on imaging and palpable? she has multiple endocrine neoplasia (MEN) 2B
syndrome. What potential abnormalities would
A. FNA
you suspect and work up?
B. Repeat lab work
C. Follow-up with repeat ultrasound in 6 months A. Papillary thyroid cancer
D. Subtotal thyroidectomy B. Pituitary adenoma
C. Pheochromocytoma
3. What would be your treatment option i the 1.1 cm D. Parathyroid hyperplasia
lesion showed suspicion or a papillary thyroid E. Hirschsprungs

http://surgerybook.net/
216 G EN ERAL S U RG ERY EXAM I N ATIO N AN D BO ARD REVI EW
ANSWERS
1. C. T yroid nodules are common with approximately
4% o the population having a palpable nodule and
more than 50% having a nodule on ultrasound. Per
Durante et al., the majority o patients with asymp-
tomatic, sonographically or cytologically benign thy-
roid nodules will not undergo any signi cant size
increase or display cancer at ve years. No FNA or
surgery is required or this nodule per the Ameri-
can T yroid Association (A A) 2015 guidelines and
repeating lab work is not indicated or this patient.
T e A A in their 2015 guidelines recommend con-
sidering repeat ultrasound at 612 months or nod-
ules with highly suspicious ultrasound patterns
(hypoechoic, taller than wide) and 1224 months or
nodules with low to intermediate suspicion on ultra-
sound pattern (iso or hyperechoic, hypoechoic with
smooth margins and no microcalci cations).
2. A. T e A A and the AACE recommend biopsy i the
nodules are > 1 cm. T e A A recommends biopsy o
subcentimeter nodules larger than 5 mm that are
suspicious appearing on ultrasound (hypoechoic
with microcalci cations) and individuals with a high
risk history (e.g., amily history o papillary thyroid
cancer, history o irradiation as a child or adolescent,
prior hemithyroidectomy with discovery o thyroid
cancer, and positron emission tomography (PE )
positive thyroid nodules). T e AACE recommends
biopsy o nodules o any size or suspicious history
(e.g., history o irradiation in childhood or adoles-
cence, amily history o thyroid cancer or MEN syn-
drome, previous thyroid surgery or cancer, increased
calcitonin levels) or suspicious ultrasound ndings
(e.g., hypoechogenicity, irregular borders, microcal-
ci cations, taller than wide, chaotic intranodular vas-
cular images).
3. D. For patients with FNA biopsies showing thy-
roid cancer, the initial surgical procedure should be
near-total or total thyroidectomy or lesions greater
than 1 cm. T yroid lobectomy may be considered or
< 1 cm, low risk, uni ocal, intrathyroidal papillary
carcinomas in patients with no history o prior head
and neck irradiation and no evidence o cervical
nodal metastases.
http://surgerybook.net/
4. B. For indeterminate biopsies on FNA such as
ollicular neoplasms or Hurthle cell neoplasms on
pathology, the malignancy risk is approximately 20%.
T is risk increases with large tumors (> 4 cm) and
pathology ndings consistent with cellular pleomor-
phism or other atypia and suspicion or papillary car-
cinoma. Other risk actors include amily history o
thyroid carcinoma and previous radiation exposure.
Per the 2015 A A guidelines, or patients with an
isolated indeterminate solitary nodule, thyroid lobec-
tomy is the recommended initial surgical approach.
otal thyroidectomy is recommended or indetermi-
nate nodules which are large (> 4 cm), show marked
atypia present on biopsy, in patients with a amily
history o thyroid cancer, in patients with a history
o radiation exposure, or or those with FNA biopsy
results suspicious or papillary carcinoma.
5. C. T e MEN 2B syndrome is characterized by med-
ullary thyroid cancer, pheochromocytomas, and
mucosal neuromas as well as mar anoid appearance.
MEN 2A syndrome is characterized by medullary
thyroid cancer, pheochromocytomas, and parathy-
roid hyperplasia causing hyperparathyroidism as
well as Hirschsprungs and cutaneous lichen amyloi-
dosis. MEN 1 syndrome is characterized primarily by
pituitary, pancreatic, and parathyroid tumors.
BIBLIOGRAPHY
Durante C, Costante G, Lucisano G, et al. T e natural history
o benign thyroid nodules. JAMA. 2015;313(9):92635.
Gharib H, Papini E, Baskin HJ, et al. American association o
clinical endocrinologists and associazione medici endocri-
nologi medical guidelines or clinical practice or the diag-
nosis and management o thyroid nodules. Endocr Pract.
January-February 2006;12(1): 63102.
Haugen BR, Alexander EK, Bible KC, et al. 2015 American
T yroid Association Management Guidelines or Adult
Patients with T yroid Nodules and Dif erentiated T yroid
Cancer: T e American T yroid Association Guidelines
ask Force on T yroid Nodules and Dif erentiated T yroid
Cancer. T yroid. January 2016;26(1):1133.
Levine RA. Current guidelines or the management o thyroid
nodules. Endocr Pract. July-August 2012;18(4):5969.
Raue F, Frank-Raue K. Genotype-phenotype relationship in
multiple endocrine neoplasia type 2: Implications or clini-
cal management. Hormones. 2009;8(1):238.
T akker RV, Newey PJ, Walls GV, et al. Clinical practice guide-
lines or multiple endocrine neoplasia ype 1 (MEN1).
J Clin Endocrinol Metab. September 2012;97(9):29903011.
 61
Pancreatic Endocrine umors
Jigesh A. Shah and Omar Yusef Kudsi
1. T e patient from the previous question denies any
family history of multiple endocrine neoplasia
(MEN). In regards to MEN syndromes, which of
the following is correct?
A. T e most common endocrinopathies in MEN-1
are pituitary adenomas, reaching 100% penetra-
tion by age 50.
B. T e most common endocrinopathy in MEN-2 is
pheochromocytoma.
C. MEN-2B includes medullary thyroid cancer and
pheochromocytoma in all patients.
D. Prophylactic thyroidectomy is not recom-
mended in patients with a con rmed RE germ-
line mutation and a discernable thyroid mass
by ultrasound i the serum calcitonin levels are
normal.
E. During work up or a MEN, i a pheochromo-
cytoma is detected it should be resected prior to
surgery on the thyroid.
2. A 40-year-old male was found to have recurrent
hypoglycemic symptoms with a plasma glucose
level of 44 mg/dL and a C-peptide level of
200 pmol/L. He has relief of his symptoms with
the administration of glucose. Further workup
includes a positive 72-hour fast. In regards to
pancreatic neuroendocrine tumors, which of the
following is true?
A. Pancreatic neuroendocrine tumors (PNE s)
are common and 75% o cases are ound in
association with symptoms related to a speci c
hormone.
http://surgerybook.net/
B. With PNE lesions located in the body or tail
o the pancreas, a distal pancreatectomy can be
per ormed and even i the lesion is thought to
be malignant, splenic preservation may still be
attempted.
C. Enucleation and ormal resection o PNE s gen-
erally lead to equivalent outcomes or the man-
agement o small PNE s less than 2 cm.
D. Most non unctional PNE s are benign, even
i they have local invasion and regional lymph
node involvement.
E. Formal resection with appropriate lymphade-
nectomy is recommended or patients with insu-
linoma/gastrinoma smaller than 2 cm and other
unctional tumors such as VIPoma, somatostati-
noma, and glucagonoma which demonstrate no
evidence o metastatic disease.
3. You are evaluating a 50-year-old male with a
history of recurrent duodenal ulcers located in the
second portion of the duodenum. Further work-
up demonstrates that he is H. pylori negative and
an upper endoscopy shows markedly hypertrophic
gastric folds. Which of the following is true
regarding his likely underlying diagnosis?
A. A asting serum gastrin level o more than
1,000 pg/mL (normal is < 100 pg/mL) is consid-
ered diagnostic or gastrinoma.
B. Following intravenous secretin injection, an
idiosyncratic rise in serum gastrin o 10 pg/mL
is diagnostic.
C. T e majority o gastrinomas are generally ound
within the gastrinoma triangle, which is bound
218 G EN ERAL S U RG ERY EXAM I N ATIO N AN D BO ARD REVI EW
by the junction o the cystic and common bile
duct, the junction o the rst and second portion
o the duodenum and the junction o the neck
and body o the pancreas.
D. Gastrinomas are commonly ound in locations
such as the gallbladder, renal capsule, splenic
hilum, mesentery, omentum, ovary, lymph nodes,
and heart.
E. Medical treatment o Zollinger-Ellison Syn-
drome with proton pump inhibitors is very e ec-
tive, eliminating any malignant potential, thus
preventing the progression o malignant disease.
4. A 59-year-old male patient presents with diabetes,
anemia, and a 30 pound weight loss. Recently,
he started to develop a rash described as raised
erythematous plaques that developed central
bullae that sloughed, leaving necrotic centers
and serous crusts. Serum glucagon levels are
1100 pg/dL. A C scan of the abdomen and
pelvis demonstrated a 4 cm mass in the tail of the
pancreas. Which of the following is true regarding
his diagnosis?
A. Localization with C and staging with soma-
tostatin receptor scintigraphy are generally
insu cient or obtaining a diagnosis, despite the
large size and somatostatin-rich receptor status
o these tumors.
B. Necrolytic migratory erythema occurs in
approximately 5% o these patients.
C. Deep venous thrombosis and thromboembolism
are quite common and patients should be ully
anticoagulated at the time o diagnosis and in e-
rior vena cava lters should be considered pre-
operatively.
D. Glucagonomas are most commonly located in
the head o the pancreas and are usually sensi-
tive to chemotherapy.
E. When per orming a distal pancreatectomy and
splenectomy or a distal pancreatic glucagonoma,
a cholecystectomy should not be routinely per-
ormed.
ANSWERS
1. E. MEN-1 is mani ested by hyperparathyroidism,
pituitary adenomas, and pancreatic neuroendocrine
tumors. MEN-2A is mani ested by medullary thyroid
cancer in nearly all patients but pheochromocytoma
develops in only 40% to 50% o patients.
http://surgerybook.net/
Hyperparathyroidism occurs in approximately
20% o patients. Medullary thyroid cancer (M C) is
typically the rst presenting endocrine tumor mani-
esting between the age o 5 and 25 years. MEN-2B
is relatively rare, accounting or less than 10% o the
cases o amilial medullary thyroid cancers. T is
syndrome includes medullary thyroid cancer in all
patients and pheochromocytoma in approximately
50%. A ected patients also exhibit a mar anoid body
habitus, enlarged lips, and have mucosal neuromas o
the eyelids, lips, and tongue.
MEN-2B is an aggressive orm o MEN-2 in that
M C tends to present earlier than in MEN-2A or
amilial medullary thyroid carcinoma (FM C), o en
during the rst year o li e. I a carrier state is identi-
ed in a pre-clinical setting, surgery should be done
be ore the age o typical onset o cancer or metasta-
sis. In a prophylactic setting, the procedure o choice
is a total thyroidectomy. I the patient has an elevated
calcitonin level, then a total thyroidectomy and cen-
tral neck dissection should be done. Genetic testing
dictates strati ed management o the thyroid. T e
American T yroid Association (A A) has developed
risk groups based on the speci c mutation. Carriers
with MEN-2B should have a thyroidectomy within
the rst six months. Patients with MEN-2 should
have a thyroidectomy be ore the age o ve and
patients with the lowest level o risk should have a
thyroidectomy between the ages o 5 and 10 years.
Similarly, identi cation o the speci c codon will
dictate screening and management or pheochromo-
cytomas and hyperparathyroidism.
2. C. PNE s are uncommon in the general population,
accounting or only 3% to 5% o pancreatic malig-
nancies, a majority o which are sporadic and unc-
tional. Several important actors must be considered
when selecting the operative approach to, including
the tumors unctional status, benign or malignant
nature, involvement with contiguous structures,
presence o metastatic disease, and whether the
tumor is sporadic or associated with a genetic syn-
drome. Clinical symptoms and biochemical evidence
o hormone excess determine the tumors unctional
status. Preoperative evaluation by cross-sectional
and unctional (somatostatin) imaging combined
with endoscopic ultrasound can help determine the
tumors benign or malignant nature by delineating
the degree o local invasion, lymph node involve-
ment, and metastases to the liver and elsewhere.
 C H AP TER 6 1 PAN C REATIC EN D O C RIN E TU M O RS
Endoscopic ne needle aspiration biopsy can con rm
the presence o neuroendocrine cells and may help
determine the proli erative index (Ki67) which in
turn can help grade the likelihood o malignancy.
An accurate history and genetic testing can deter-
mine whether the tumor is sporadic or associated
with a genetic syndrome and must be considered
during preoperative decision making and planning
or resection. T e goal o surgery or primary PNE s
is to resect the primary tumor and associated lymph
nodes while preserving the maximal amount o pan-
creatic mass. T e indications or surgery in patients
with PNE s include systemic symptoms due to hor-
mone overproduction, local compressive symptoms
Figure 61-1. Gastrinoma riangle.
due to mass e ect, and prevention o malignant
trans ormation or dissemination. Formal pancre-
atic resection with appropriate lymphadenectomy is
recommended or patients with established known
malignancy, including splenectomy when lesions are
ound within the tail o the pancreas. With insulino-
mas/gastrinomas larger than 2 cm and other unc-
tional tumors such as VIPoma, somatostatinoma, and
glucagonoma who have no evidence o metastatic
disease a ormal resection is the pre erred operative
management strategy. For those lesions smaller than
2 cm, the survival o simple enucleation is similar to
a ormal resection.
3. A. Gastrinomas are associated with Zollinger-
Ellison syndrome (atypical peptic ulcer disease,
gastric hyperacidity and hyper-secretion). Proton-
pump inhibitors have no e ect on the natural his-
tory o the disease. Most patients are male ( 60%)
and the average age at diagnosis is about 60 years. A
asting serum gastrin level o more than 1000 pg/mL
(10 times the upper limit o normal) is diagnostic o
Syndrome Chromosome Gene
MEN 1 Chromosome 11 MENIN
MEN 2A Chromosome 10 RE proto-oncogene
MEN 2B Chromosome 10 RE proto-oncogene
MEN Multiple Endocrine Neoplasia, RE REarranged during rans ection.
http://surgerybook.net/
219
Right of S MA Le ft of S MA
S MV S MA
gastrinomas. Gastrinomas can be distinguished rom
these other conditions by virtue o its paradoxical
e ect on serum gastrin levels in response to a secretin
in usion (secretin stimulation test). A er baseline
gastrin measurement, secretin is administered and
gastrin levels are rechecked. An increase in gastrin
levels o greater than 120 pg/mL over basal levels has
94% sensitivity and 100% speci city or gastrinoma.
T e majority o gastrinomas are generally ound
within the gastrinoma triangle, which is bound by
the junction o the cystic and common bile duct,
the junction o the second and third portion o the
duodenum and the junction o the neck and body
o the pancreas. Localization o gastrinomas is best
per ormed with endoscopic ultrasonography and
somatostatin-receptor scintigraphy. Because o the
malignant potential o gastrinomas, medical treat-
ment alone does not prevent progression o malig-
nant disease and with the development o excellent
pharmacologic therapy or the control o gastric acid
Associated Pathology
Parathyroid Hyperplasia (4-gland)
Pancreatic Islet Cell umors (Gastrinoma)
Pituitary umors (Prolactinoma)
Parathyroid Hyperplasia (4-gland)
Pheochromocytoma
Medullary T yroid Carcinoma
Pheochromocytoma
Medullary T yroid Carcinoma
Mucocutaneous Ganglioneuroma, Mar anoid
Body Habitus
220 G EN ERAL S U RG ERY EXAM IN ATI O N AN D BO ARD REVIEW
hypersecretion, surgery or gastrinomas has shi ed
toward tumor localization and resection.
4. C. Glucagonomas have been described as caus-
ing the 4 Ds: dermatitis, diabetes, depression, and
deep vein thrombosis. Weight loss and a character-
istic skin rash (necrolytic migratory erythema) are
the most common presenting eatures, occurring in
about 70% o patients, with other symptoms occur-
ring less requently at initial presentation. Necrolytic
migratory erythema, which is an intensely pruritic
rash that usually presents on the lower abdomen,
perineum, perioral area, or lower extremities, may
present be ore any other signs or symptoms and is
pathognomonic or glucagonoma and is ound in up
to 70% o patients. Most glucagonoma patients have
glucose intolerance and asting serum glucagon lev-
els between 1000 and 5000 pg/mL.
T e initial management o a patient with a gluca-
gonoma should ocus on blocking and treating the
metabolic e ects o glucagon hypersecretion and
preventing or treating venous thromboembolism.
Octreotide and intravenous f uids should be admin-
istered. Additionally, due to their hypercoagulable
state and predisposition to thromboembolic events,
patients should be ully anticoagulated. Glucagono-
mas are most commonly located in the tail o the
pancreas and surgical resection usually consists o
a distal pancreatectomy along with a splenectomy.
A cholecystectomy should be per ormed prophylac-
tically at the time o the initial operation to elimi-
nate the potential or gallstone related complications
which are associated with octreotide therapy.
http://surgerybook.net/
BIBLIOGRAPHY
Brandi ML, Gagel RF, Angeli A, et al. Guidelines or diagnosis
and therapy o MEN type 1 and 2. J Clin Endocrinol Metab.
2001;86:565871.
Gold nger SE. Zollinger-Ellison syndrome (gastrinoma):
Clinical mani estations and diagnosis. Available at:
http://www.uptodate.com/contents/zollinger-ellison-syndrome-
gastrinoma-clinical-mani estations-and-diagnosis?source=
search_result&search=Gold nger+SE+Zollinger-Ellison+
syndrome+%28gastrinoma%29%3A+Clinical+mani estations+
and+diagnosis&selected itle=1~150.
Kloos R , Eng C, Evans DB, et al: Medullary thyroid cancer:
Management guidelines o the American T yroid Associa-
tion. T yroid. 2009;19:565612.
Norton JA, Fraker DL, Alexander HR, et al. Surgery increases
survival in patients with gastrinoma. Ann Surg. 2006;44(3):
41019.
ORiordain DS, OBrien , Crotty B, et al. Multiple endo-
crine neoplasia type 2B: More than an endocrine disorder.
Surgery. 1995;118:93642.
Passaro E, Howard J, Sawicki MP, et al. T e origin o sporadic
gastrinomas within the gastrinoma triangle: A theory. Arch
Surg. 1998;133(1):1316.
Phan GQ, Yeo CJ, Hruban RH, et al. Surgical experience with
pancreatic and peripancreatic neuroendocrine tumors:
Review o 125 patients. J Gastrointest Surg. 1998;2:473.
Pitt SC, Pitt HA, Baker MS, et al. Small pancreatic and peri-
ampullary neuroendocrine tumors: resect or enucleate?
J Gastrointest Surg. 2009;13:1692.
Plockinger U, Rindi G, Arnold R, et al. Guidelines or the diag-
nosis and treatment o neuroendocrine gastrointestinal
tumours. A consensus statement on behal o the European
Neuroendocrine umour Society (ENE S). Neuroendocri-
nology. 2004;80:394424.
Stabile BE, Morrow DJ, Passaro E Jr. T e gastrinoma triangle:
Operative implications. Am J Surg. 1984;147:2531.
Wermers RA, Fatourechi V, Wynne AG, et al. T e gluca-
gonoma syndrome. Clinical and pathologic eatures in 27
patients. Medicine. 1996;75(2):5363.
 62
Salivary Gland umors

Maxwell Sirkin and William V. Rice

A 55-year-old Caucasian male is re erred to your clinic A. otal parotidectomy

or a palpable 2 cm mass located 2 to 3 cm anterior to B. Super cial parotidectomy, sparing the acial
his right tragus. He states that it has been present or nerve
about 9 months and has slowly been getting larger. He C. Super cial parotidectomy, sacri cing any acial
denies any pain, acial weakness or numbness, evers, nerve that may be involved
weight loss, atigue, and dry mouth. He has no medi- D. Enucleation o the mass, sparing nerve and nor-
cal or surgical history and does not take any medica- mal glandular tissue
tions. On physical exam you nd a well-circumscribed, E. Surveillance o the mass with serial computer-
mobile, non-tender 2 cm mass, with no overlying skin ized tomography (C ) scans
changes. T ere is no lymphadenopathy and the rest o
the exam is normal. 4. Tissue and diagnostic studies instead reveal a high
grade mucoepidermoid carcinoma that is clearly
1. Regarding the above patient, which o the ollow- deep to the acial nerve. What is the next best step?
ing is the most likely diagnosis? A. otal parotidectomy with resection o any adja-
A. Mucoepidermoid carcinoma cent acial nerve and immediate interposition
B. Adenoid cystic carcinoma nerve gra
C. Pleomorphic adenoma B. otal parotidectomy with sparing o the acial
D. Papillary cystadenoma lymphomatosum nerve, ollowed with post-operative radiation
E. Sjogrens syndrome related glandular enlarge- C. Radiation and chemotherapy with post-treatment
ment surveillance
D. Radiation alone with post-treatment surveil-
2. Which o the ollowing studies is the next best step lance
in the diagnostic workup? E. Super cial parotidectomy, sparing the acial
A. Core needle biopsy nerve, ollowed with post-operative radiation
B. Incisional biopsy
C. Positron emission tomography (PE ) scan 5. A month a er the operation the patient returns to
D. Fine needle aspiration (FNA) your clinic complaining o f ushing and sweating
E. Ultrasound on the right side o his ace when he eats. What is
the cause o this?
3. Tissue and imaging studies reveal a pleomorphic A. Cross innervation between para-sympathetic
adenoma that appears to be con ned to the bers rom the superior salvatory nucleus with
super cial parotid gland. What is the next best sympathetic bers rom the superior cervical
step? ganglion to the skin

http://surgerybook.net/
222 G EN ERAL S U RG ERY EXAM IN ATIO N AN D BO ARD REVI EW
B. Cross innervation between bers in the auricu-
lotemporal nerve with sympathetic bers to the
skin
C. Cross innervation between bers in branches o
the acial nerve with sympathetic bers to the
skin and sweat glands
D. Cellulitis
E. Changes in the skin caused by congestion o
dermal lymphatics
ANSWERS
1. C. Most salivary gland tumors arise in the parotid
gland (70%) with ewer being ound in the subman-
dibular gland (20%). T e larger the gland, the more
likely the tumor will be benign. In the parotid gland
80% o tumors will be benign. Submandibular glands
have a ratio o 50:50 and minor salivary glands have
a ratio o 25:75 benign to malignant, respectively.
Signs and symptoms including pain, rapid growth,
nerve weakness, paresthesias, cervical lymphad-
enopathy, and xation to underlying tissue are all
concerning or malignancy. Skin changes, purulent
drainage, evers, chills, and tenderness to palpation
are more indicative o an in ectious cause or granu-
lomatous disease. Dry mouth or mucus membranes,
with bilateral swelling is associated with Sjogrens
disease.
It is important to realize that pleomorphic adeno-
mas, a benign tumor, are the most common tumors
in the parotid gland and account or 40% to 70%. T e
second most common tumor is a papillary cystad-
enoma lymphomatosum, also known as a Warthins
tumor. T is tumor is also benign with a higher pro-
pensity to be bilateral. Mucoepidermoid carcinoma
is the most common malignant tumor o the parotid
gland. Adenoid cystic carcinomas, which are malig-
nant, are the most common tumors o the subman-
dibular and minor salivary glands.
2. D. T is patients signs and symptoms suggest a
benign tumor, however malignancy may be present.
T ere ore, tissue diagnosis is recommended prior
to proceeding with surgical intervention. T e next
best step or surgical planning and patient coun-
seling would be to obtain tissue preoperatively with
a ne needle aspiration. FNA has excellent sensitivity
(92%), speci city (100%), and accuracy (98%). FNA
with or without ultrasound guidance would be the
initial study o choice.
http://surgerybook.net/
MRI and C scans are being used more requently
to help assess or regional lymphadenopathy, extent/
depth o tumor and tumor location in relationship
to other important structures. Core needle biopsy in
the ace and neck is usually not recommended due
to the proximity o sensitive structures. Ultrasound
alone, without an FNA, will yield little additional
value than what a C , MRI, and FNA will provide
and may be considered a waste o time and resources.
PE is help ul in tumors that are PE avid, such as
Warthins tumors, or when there is concern or dis-
tant disease. PE is not recommended as part o the
routine workup.
Incisional biopsy o the tumor or tissue diagno-
sis is not recommended due to high recurrence rates,
concerns or seeding, and the potential to turn a sin-
gle lesion into multiple lesions. T e thought is that
an incisional biopsy will not entirely remove a single
lesion and when the disease recurs it will recur in
multiple locations due to the tumor le behind rom
the initial biopsy.
3. B. Pleomorphic adenomas rarely extend into the
deep space and a super cial parotidectomy should
be the rst surgical intervention or most o these
benign tumors. Pleomorphic adenomas do not
invade into the nerve and all attempts should be made
to identi y and spare the acial nerve and its branches
during the surgery. For a benign tumor, resecting the
least amount o tissue will result in superior cosmetic
outcomes and results in less potential or injury to
the acial nerve. I the tumor is benign and has no
obvious invasion into the deep lobe then all that is
required is a super cial parotidectomy.
otal parotidectomy is not necessary in the
patient unless intraoperative ndings show involve-
ment o the deep lobe. Enucleation o the tumor is
not recommended as there is a high risk or recur-
rence when this is per ormed. Surveillance o parotid
gland tumors with serial examination and C is rec-
ommended or certain Warthins tumors in patients
that have contraindications to surgery, but is oth-
erwise not recommended or either malignant or
benign tumors o the salivary glands.
4. B. In this patient there is involvement o the deep
lobe, which is an indication or total parotidectomy.
Since the patient has no neurologic symptoms prior
to the operation, i the nerve is not being visibly/
directly invaded then you should attempt to dissect

the tumor o o the nerve ollowed by post-operative
radiation. You should still plan or the potential
need to do a nerve harvest and gra , should you
nd that there is nerve invasion during the opera-
tion. T e sural nerve and greater auricular nerve
are commonly used conduits. Some sources suggest
that malignant tumor con ned to the super cial
lobe with no obvious peri-neural involvement can
be treated with a super cial parotidectomy, dissec-
tion o the tumor o o the acial nerve, ollowed by
post-operative radiation. Non-surgical management,
preoperative chemotherapy and radiation only o
malignant salivary tumors are not currently recom-
mended methods o treatment.
Malignant salivary tumors are staged according to
size and degree o local invasion. T ey are also classi-
ed according to histological grade which separates
them into either high or low, based on the number
o mucoid cells and epidermoid components. High
grade tumors indicate a more aggressive tumor and
thus exhibit a worse prognosis. High grade histol-
ogy is typically an indication or an ipsilateral neck
dissection. Indications or post-operative radiation
include: high grade, extra-glandular involvement,
peri-neural invasion, direct invasion o surrounding
structures, dissection o tumor o the acial nerve
and distant metastatic disease.
5. B. Freys syndrome is a rare complication o parotid
tumor surgery and is the result o necessary injury
to the auriculotemporal nerve when resecting the
parotid gland. T e auriculotemporal nerve has par-
asympathetic bers that trigger secretion o saliva
rom the parotid gland. When these bers are injured
during parotidectomy and undergo healing, they can
sometimes cross innervate with sympathetic nerve
bers that travel to the skin and sweat glands. T e
result is gustatory sweating or triggering o the
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C H AP TER 6 2 S ALI VARY G LAN D TU M O RS 223
sweat glands rom signals in the auriculotemporal
nerve, meant to trigger salivation in a gland that no
longer exists or has had part o it removed.
Option A describes a phenomenon that is ound
when submandibular glands or minor salivary glands
are injured and is similar to Freys syndrome in the
sense that it is caused by aberrant nerve regeneration.
However, it involves di erent nerves and would not
present as a result o parotid surgery.
Cellulitis is usually accompanied by pain and con-
tinuous redness, not sweating, and is usually sooner
a er the operation. Congestion o dermal lymphatics
would create a peau dorange appearance o the skin
and is usually associated more with inf ammatory
breast cancer not salivary gland tumors.
BIBLIOGRAPHY
Gordon AB, Fiddian RV. Freys syndrome a er parotid sur-
gery. Am J Surg. 1976;132(1):548.
Kaplan M, Abemayor E. Major salivary glands. In: Fu YS,
Wenig BM, Abemayor E, et al., eds. Head and Neck Pathol-
ogy: With Clinical Correlations. New York, NY: Churchill-
Livingstone; 2001:231.
Lorenz RR, Couch ME, Burkey BB. Head and Neck. In: Beau-
champ DR, ownsend CM, Evers MB, Mattox KL. Sabiston
extbook o Surgery: T e Biological Basis o Modern Surgi-
cal Practice. 19th ed. Philadelphia, PA: Elsevier Saunders;
2012:81113.
Miller MC, Moyer JS, eknos N. Head and Neck. In: Mulhol-
land MW, Lillemoe KD, Doherty GM, et al. Greenf elds Sur-
gery: Scientif c Principles & Practice. 5th ed. Philadelphia,
PA: Lippincott Williams & Wilkins; 2011:6157.
Rahbar R, Grimmer FJ, Vargas SO, et al. Mucoepidermoid
carcinoma o the parotid gland in children: A 10-year
experience. Arch Otolaryngol Head Neck Surg. 2006;132:
37580.
Stewart CJ, MacKenzie K, McGarry GW, et al. Fine-needle
aspiration cytology o salivary gland: A review o 341 cases.
Diagn Cytopathol. 2000;22:13946.
Witt RL: T e signi cance o the margin in parotid surgery or
pleomorphic adenoma. Laryngoscope. 2002;112:214154.
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Pediat r ic Sur g er y
Mary J. Edwards

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 63
Head and Neck Pediatric umors
Margaret E. Clark
A 4-year-old girl is brought in to see her primary care
provider (PCP) by her parents. T ey have noticed a
small mass on the anterior portion o her neck, but
recently started noticing that it was spontaneously
draining and has become erythematous. Her PCP has
the girl stick out her tongue and notices that the mass
moves with tongue protrusion. T e physician correctly
identi es that this is likely an in ected thyroglossal duct
cyst. She appropriately places the child on antibiotics,
covering or oral ora, and then re ers the child to sur-
gery or operative intervention, delayed until the in ec-
tion clears.
1. What is the most appropriate treatment or a
thyroglossal duct cyst?
A. Surgical resection o the cyst, taking care to only
remove the cyst and not disturb any o the criti-
cal surrounding neck structures
B. Resection o the thyroglossal duct and the com-
plete hyoid bone
C. Removal o the cyst en bloc, excising a core o
tissue around the tract to the base o the tongue,
and including the central 1/3rd o the hyoid
bone
D. otal thyroidectomy
2. Regarding branchial clef cysts, which o the
ollowing statements is correct?
A. T e rst branchial cle extends to the audi-
tory canal, placing both the acial nerve and the
parotid at risk or injury.
B. ype I cysts are the most common, accounting
or 80% to 90% o all lesions.
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C. When a child presents with an in ected bran-
chial cle cyst, unlike a thyroglossal duct cyst, it
is imperative to per orm resection immediately
to control the in ection and prevent urther com-
plications.
D. I a cyst is located on the anterior border o the
sternocleidomastoid muscle it is a type II bran-
chial cle cyst.
3. Which o the ollowing statements is true regarding
the presentation, diagnosis, and management o a
lymphatic mal ormation?
A. Lymphatic mal ormations never present with
airway compromise given their position in the
posterior neck.
B. Ninety percent o lymphatic mal ormations are
apparent at birth, with most diagnosed during
prenatal ultrasound.
C. Fine needle aspiration (FNA) is necessary to
con rm the diagnosis o a lymphatic mal orma-
tion prior to resection.
D. Given that lymphatic mal ormations are benign,
radical resection should never be per ormed, due
to the lesions close association or proximity to
vital structures.
E. All o the above are true.
4. What is the most common childhood malignancy
presenting as a head or neck mass in children over
the age o 5?
A. T yroid carcinoma
B. Lymphoma
228 G EN ERAL S U RG ERY EXAM IN ATI O N AN D BO ARD REVIEW
C. Rhabdomyosarcoma
D. Neuroblastoma
E. Melanoma
5. Which o the ollowing is true regarding treatment
or torticollis?
A. Division o the sternocleidomastoid muscle is
only indicated i the in ant has plagiocephaly or
hemihypoplasia.
B. Botulinum toxin injection should be the rst
treatment, ideally preventing the in ant rom
needing to undergo physical therapy.
C. Physical therapy, with passive range o motion
and neck-stretching, is the primary treatment
modality.
D. Ocular imbalance causing torticollis will be xed
by corrective lenses.
ANSWERS
1. C. T yroglossal duct cysts are ound in the midline
o the neck. T ese are the second most common con-
genital pediatric neck masses, though the most com-
mon midline anomaly. T ough classically described
as midline, up to 40% may actually lie just lateral to
the midline. T ese cysts, based on their embryological
descent, are ound to have a tract extending rom the
hyoid bone up to the base o the tongue. T e normal
thyroglossal duct involutes by the eighth etal week,
with remnants leading to cyst ormation or ectopic
thyroid tissue anywhere along the tract. Approxi-
mately 60% o these cysts lie adjacent to the hyoid
bone, 24% lie above, and 13% lie below the hyoid
bone. Cysts may also present intralingually, with
2% occurring at the base o the tongue, which may
place a neonate at risk or airway obstruction. Sur-
gery involves removal o the middle 1/3 o the hyoid
bone, called the Sistrunk procedure, with removal o
the hyoid necessary to prevent recurrence.
T is procedure was rst described in 1920, and he
described the importance o an en bloc dissection,
excising a core o tissue around the tract, necessary
given the possible existence o multiple tracts. Recur-
rence rates are less than 10% and usually related to
incomplete excision or intraoperative rupture. T ere
is a possible association between preoperative in ec-
tion and risk o recurrence, though not con rmed
in recent analyses. T ese congenital lesions have the
potential or malignant trans ormation, with papil-
lary adenocarcinoma ound in up to 10% o adults
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presenting with a thyroglossal duct cyst. Papillary
carcinoma can arise in adulthood rom the dysge-
netic ectopic thyroid tissue and is reason to per orm
complete excision o the lesion in a child with a thy-
roglossal duct cyst or sinus. T ough these cysts, simi-
larly to branchial cle cysts, o en present with an
acute in ection during childhood, up to 40% present
a er the age o 20. Dermoid cysts are o en usually
ound midline on the neck, potentially being con-
used with a thyroglossal duct cyst. However, they
are not associated with the thyroid and will not move
when the patient swallows or with protrusion o the
tongue, as opposed to a thyroglossal duct cyst. It is
recommended that the presence o normal thyroid
tissue outside o the thyroglossal duct cyst is con-
rmed prior to excision. Ectopic thyroid tissue is
identi ed in surgical specimens in approximately
25% to 35% o cases, though it is actually rare that
this is the childs only thyroid tissue. However, i thy-
roid tissue is noted in the resected specimen thyroid
scanning is still indicated to identi y the child that
may require li elong thyroid hormone replacement.
2. A. T e di erential diagnosis o a lateral neck mass is
extensive and includes branchial cle remnants, lym-
phatic mal ormation, dermoid cyst, hemangioma,
lymphadenitis, torticollis, neuro broma, lipoma, or
metastatic malignancy to the cervical lymph nodes.
Branchial cle cysts are the most common congeni-
tal neck lesion, accounting or approximately 20%
to 30% o all pediatric neck masses. Sinuses, stulas,
and remnants are usually noticed at birth or early
in li e, opposed to branchial cle cysts which are
more likely to present later in childhood. T ere are
six paired branchial arches, containing ectodermal,
mesodermal, and endodermal components.
Understanding the relationships o these arch
components is help ul to conceptualize and catego-
rize congenital neck masses. T e dorsal portion o
the rst cle becomes the external auditory canal.
Given this tracts location, it places the acial nerve
at risk or injury during resection. ype II is the most
common abnormality, with 90% to 95% o cases.
T ey are ound along the anterior border o the ster-
nocleidomastoid muscle (SCM) and may be bilat-
eral in 10% o cases. Anomalies o the third cle are
extremely rare, but are also located along the ante-
rior border o the SCM. However, they are usually
lower in the neck and pass lateral to the carotid
bi urcation rather than through it. Sinus tracts o the
 C H AP TER 6 3 H EAD AN D N EC k P ED IATRI C TU M O RS
second branchial anomalies pass between the exter-
nal and internal carotid arteries, entering the lateral
wall o the pharynx at the tonsillar ossa. Congenital
lesions may present while acutely in ected, and prior
to operative intervention their close relationships to
major nerves and vessels needs to be understood.
Injury to the parotid gland and acial nerve may
occur rom recurrent in ection o a ype I branchial
cle cyst, or rom a complication o an incision and
draining. In ection o the third and ourth branchial
cle cysts are rare and more challenging to diagnose
and treat. Suppurative thyroiditis may be due to an
in ected third or ourth arch sinus. ype III and IV
cysts may cause airway edema and dif culty swal-
lowing, which can o en be controlled by controlling
the acute in ection.
It is important that the cysts and their stula tracts
be excised a er the acute in ection has been cleared
in order to prevent recurrence. T e initial treatment
is antibiotics and not surgery. Surgery is usually
6 weeks later, and the entire tract, to include the skin
punctum i present, needs to be removed as recurrent
in ections are common with incomplete removal. In
an in ant, surgery may be delayed until age 3 to 6
months. Figure 63-1 demonstrates the relationships
Firs t bra nchia l
cys t a nd fis tula
S e cond bra nchia l
fis tula
Third bra nchia l
fis tula
Figure 63-1 A child with a cle cyst and remnants o the rst
three branchial systems. Note the important relation to the
sternocleidomastoid muscle and stulas origin. (Reprinted
with permission rom Welch KJ, Randolph JG, Ravitch MM,
et al. editors. Pediatric Surgery. 4th ed. Chicago: Year Book
Medical; 1986, p. 543.)
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229
between the rst, second, and third branchial cysts
and stulas.
3. D. Lymphatic mal ormations, previously re erred
to as cystic hygromas or lymphangiomas, are most
commonly located in the head and neck, speci cally
in the posterior triangle o the neck. However, they
can occur in other locations, and when they involve
the tongue or the mediastinum they may result in
airway compromise, or in dysphagia and ailure to
thrive. T ese are vascular mal ormations, occurring
in 1 out o every 2000 to 4000 births. T ey occur due
to sequestrations o lymphatic tissue that dont com-
municate with the normal lymphatic system. Ninety
percent o these lesions appear be ore the age o two,
with 50% to 65% appearing at birth. T ese lesions are
more commonly located on the le side o the neck
and i large enough may be noted on prenatal ultra-
sound.
However, lymphatic mal ormations can be ound
anywhere in the so tissues o the ace or oral cav-
ity, with other locations including the axilla, chest,
extremities, retroperitoneum, or perineum. T e
majority o these lesions are asymptomatic, though
large lesions can invade the oor o the mouth and
cause upper airway obstruction. Fine needle aspi-
ration (FNA) should not be used to diagnose a
lymphatic mal ormation due to the possibility o
hemorrhage into the lesion and subsequent rapid
expansion, causing airway compromise. T e only
indication or aspiration o the lymphatic mal orma-
tion is i there is a need to emergently decompress
the cyst to relieve airway obstruction. Spontaneous
hemorrhage within the mass may also occur, caus-
ing rapid enlargement with swelling and echymo-
sis. Hemorrhage predisposes the child or in ection
and antibiotics should be started. Complete excision
may be dif cult without involving vital structures, so
multiple debulking procedures may be per ormed.
C with intravenous contrast or magnetic resonance
angiography can be used when planning or resec-
tion to evaluate the extension rom one body space
to another and delineate associated vital structures.
Radical resection is not indicated. Sclerotherapy
has also been studied and is an option particularly
in macrocystic lesions. Picinabil (OK-432), bleomy-
cin, doxycycline, acetic acid, alcohol, and hypertonic
saline have all been used as sclerosing agents. T ere
is a small possibility o spontaneous regression in
low-stage macrocystic lymphatic mal ormations, so
230 G EN ERAL S U RG ERY EXAM IN ATI O N AN D BO ARD REVIEW
observation and monitoring may also be an option
in some o these patients.
4. B. Malignancies o the head and neck account or
approximately 12% o pediatric malignancies, with an
increasing incidence. Head and neck malignancies are
more common in 15 to 18 year olds, ollowed by age
group < 4 years. Females aged 11 to 18 are most likely
to have thyroid carcinoma. However, lymphoma is the
number one cause o a malignant head or neck mass,
with up to 80% o pediatric patients with Hodgkins
disease having cervical lymph node involvement.
T ough non-Hodgkins lymphoma is more common
in the pediatric population, it is less likely to have cer-
vical lymph node involvement. Rhabdomyosarcoma
is the most common pediatric solid tumor in the head
or neck and typically causes symptoms through local-
ized compression or in ltration.
In children under the age o 5, neuroblastoma
is the most common solid tumor. Neuroblastoma
occurs anywhere along the sympathetic chain and
may present with Horner syndrome. On imaging,
calci cations will be evident. Melanoma should also
be on the di erential o either a primary tumor in the
head and neck, or as a cause or a malignant lymph
node. Lastly, teratomas are a rare and usually benign
tumor in children, o which only 0.47 to 6% present
in the head and neck. T ough rare they are important
to be aware o , given that the majority present at birth
with respiratory distress. Despite being a benign dis-
ease, head and neck teratomas carry a 12.5% to 23%
risk o intrauterine or neonatal death.
5. C. orticollis occurs rom brosis and shortening o
the SCM and has an incidence as high as 16% in the
newborn population. T is brosis and shortening
causes a mass in the muscle that causes the in ant
to turn his ace toward the contralateral side and tilt
the head towards the ipsilateral shoulder. In children
who can walk, they may compensate or their torti-
collis by elevating one shoulder to keep their head
and eyes level. Facial and cranial asymmetries can
result rom the abnormal positioning o the childs
head i the torticollis is not treated. When the in ants
head is turned towards the contralateral side, the
contralateral occiput presses against the bed when
they are supine, and attening o the occiput then
leads to secondary attening o the ipsilateral ore-
head, re erred to as plagiocephaly. As the torticollis
resolves the plagiocephaly also typically resolves.
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T e only indication to operate, by dividing the
muscle, is acial hemihypoplasia. Here, the ipsilat-
eral side o the ace grows more slowly than the nor-
mal side, causing progressive asymmetry. Persistent
symptoms a er 1 year o conservative treatment
may also be a possible indication or surgery. T e
etiology o torticollis is usually rom trauma, though
there are other possible etiologies such as ocular
imbalance, cervical hemivertebrae, posterior ossa
tumors, deep cervical in ections, or atlanto-occipital
subluxation. An ocular imbalance is usually due to
superior oblique palsy, which is corrected surgically.
Congenital muscular torticollis is thought to be due
to etal head descent or abnormal etal positioning
during the third trimester. rauma during delivery
is another potential cause. reatment or torticol-
lis is primarily physical therapy with passive range
o motion and neck-stretching exercises. I torticol-
lis persists a er 6 months o physical therapy, then
additional workup needs to be pursued, assessing or
other potential causes such as a congenital vertebral
mal ormation, or ocular imbalance. Botulinum toxin
(botox) can also be used to assist in treatment. T e
botox enhances the e ectiveness o stretching on the
a ected side, potentially making physical therapy
more bene cial.
BIBLIOGRAPHY
Albright J , opham AK, Reilly JS. Pediatric head and neck
malignancies: U.S. incidence and trends over two decades.
Arch Otolaryngol Head Neck Surg. 2002;128(6):6559.
Allard RH. T e thyroglossal cyst. Head Neck Surg. 1982;5(2):
13446.
Alexander VRC, Manjaly JG, Pepper CM, et al. Head and
neck teratomas in children: A series o 23 cases at great
ormond street hospital. Int J Pediatr Otorhinolaryngol.
2015;79(12):200814.
Armstrong D, Pickrell K, Fetter B, Pitts W. orticollis: An anal-
ysis o 271 cases. Plast Reconstr Surg. 1965;35:1425.
Chen A, Otto KJ. Head and neck surgery and oncology. Di er-
ential diagnosis o neck masses. In: Haughey BH, Robbins
K , eds. Otolaryngology: Head & neck surgery. 5th ed.
Philadelphia, PA: Mosby Elsevier; 2003:163642.
Geddes G, Butterly MM, Patel SM, Marra S. Pediatric neck
masses. Pediatr Rev. 2013;34(3):11524; quiz 125.
Goins MR, Beasley MS. Pediatric neck masses. Oral Maxil-
lo ac Surg Clin North Am. 2012;24(3):45768.
Hutson JM, Beasley SW. T e neck. In: T e surgical exami-
nation o children. 2nd ed. Heidelberg: Springer; 2013:
10121.
Kekunnaya R, Isenberg SJ. E ect o strabismus surgery
on torticollis caused by congenital superior oblique palsy
in young children. Indian J Ophthalmol. 2014;62(3):
3226.
 C H AP TER 6 3 H EAD AN D N EC k P ED I ATRI C TU M O RS 2 31

Kuint J, Horowitz Z, Kugel C, oper L, Birenbaum E, Linder N.
Laryngeal obstruction caused by lingual thyroglossal duct
cyst presenting at birth. Am J Perinatol. 1997;14(6):3536.
Kuo AA, ritasavit S, Graham JM, Jr. Congenital muscular
torticollis and positional plagiocephaly. Pediatr Rev. 2014;
35(2):7987; quiz 87.
Laberge J, Shamberger RC, Caldamone AA, eds. Pediatric sur-
gery. 7th ed. Philadelphia, PA: Elsevier;2012.
Lillehei C. Chapter 59. Neck cysts and sinuses. In: Coran AG,
Adzick NS, Krummel M, Laberge J, Shamberger RC,
Caldamone AA, eds. Pediatric surgery. 7th ed. Philadelphia,
PA: Elsevier; 2012:75361.
Oldham K , Aiken JJ. Pediatric head and neck. In: Mulholland
MW, Lillemoe KD, Doherty GM, Maier RV, Simeone DM,
Upchurch GR, eds. Greenf elds surgery: Scientif c principles
and practice. 5th ed. Philadelphia, PA: Lippincott Williams
& Wilkins; 2011:184353.
Perkins JA, Manning SC, empero RM, et al. Lymphatic mal-
ormations: Review o current treatment. Otolaryngol Head
Neck Surg. 2010;142(6):795803, 803.e1.
Sistrunk WE. T e surgical treatment o cysts o the thyroglos-
sal tract. Ann Surg. 1920;71(2):12122.
Stellwagen L, Hubbard E, Chambers C, Jones KL. orticollis,
acial asymmetry and plagiocephaly in normal newborns.
Arch Dis Child. 2008;93(10):82731.
Woo RK, Albanese C . Pediatric surgery. In: Norton JA, Barie
PS, Bollinger RR, et al., eds. Surgery: Basic science and clini-
cal evidence. 2nd ed. New York, NY: Springer;2008:64996.

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 64
Pyloric Stenosis
Margaret E. Clark
A one-month old Caucasian boy is brought to his pri-
mary care provider (PCP) by his parents due to di -
culty eeding. T is is their rst child and they are very
concerned. T e child has been bottle- ed since birth and
almost every time he eats he has a bout o emesis. T ey
state the emesis has gotten worse; it has remained non-
bilious, but increasingly projectile. T e parents have
tried changing ormulas, but without relie . He contin-
ues to show interest in eating, as his PCP watches him
vigorously drink rom his bottle.
On exam the in ants vitals are normal or his age,
and he is a ebrile. He is well-appearing, though small
or his age. T e PCP attempts to do an abdominal exam
and thinks he eels a mass in his right upper quadrant,
but the in ant begins to cry, making the exam more di -
cult.
1. What is the most appropriate method for diagnosis
of infantile hypertrophic pyloric stenosis (IHPS)?
A. Endoscopy
B. Upper gastrointestinal contrast study (UGI)
C. Physical exam
D. Ultrasound
2. What is the usual acid-base dysfunction associated
with this condition?
A. Hyperchloremic, hyperkalemic metabolic alka-
losis with alkalotic urine
B. Hypochloremic, hypokalemic metabolic alkalo-
sis with alkalotic urine
C. Hyperchloremic, hypokalemic metabolic acidosis
with alkalotic urine
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D. Hypochloremic, hypokalemic metabolic alkalo-
sis with aciduria
E. Hyochloremic, hyperkalemic metabolic alkalosis
with aciduria
3. When is an adequate pyloromyotomy achieved?
A. When the submucosa bulges into the myotomy
site and both edges o the divided pyloric muscle
are reely mobile.
B. Division through the outer longitudinal muscle
ollowed by division through 2/3 o the inner cir-
cular muscle. Approximately 1/3 o the circular
muscle should remain intact.
C. Longitudinal incision through the pyloric
sphincter ollowed by a transverse closure.
D. When you can pass an appropriately sized bou-
gie, based on the patients weight, through the
pylorus without any resistance.
4. What is thought to be the pathogenesis of this
syndrome?
A. Congenital abnormality
B. A de ciency in neuronal nitric oxide
C. Bottle/ ormula eeding
D. Increased testosterone levels in the in ant
5. What is the most common complication to occur
with this operation, whether the operation is
performed open or laparoscopically?
A. T e in ant continues to vomit or 1 to 3 days a er
the operation.

B. Intra-operative per oration
C. Incomplete pyloromyotomy
D. Wound in ection
ANSWERS
1. D. In antile hypertrophic pyloric stenosis (IHPS) is
most common in Caucasian rst-born males. T e
di erential diagnosis o non-bilious vomiting in an
in ant includes gastroenteritis, ood allergies, gas-
troesophageal ref ux, pyloric duplication, antral web,
or increased intracranial pressure. T ough a de ni-
tive diagnosis can be made in 75% o in ants with
IHPS by care ul physical examination, it is becoming
a lost skill and is technically di cult in cases present-
ing early. I the stomach is distended, aspiration with
a nasogastric tube may assist in success ul palpation
o the olive, or enlarged pylorus on physical exam.
However, ultrasound (US) has now become not only
the most common initial imaging technique or
diagnosis, but the gold standard. T e speci city and
sensitivity o US reaches 98% and 100%, respectively.
T ere continues to be some debate over the exact
pathological pyloric measurements.
ypically a muscle thickness o > 4.0 mm and
a pyloric channel length > 15 mm are consistent
with the diagnosis. However, when in ants present
younger than 22 days, a 3.5 mm thickness may be a
more use ul or a more accurate cuto point. A mus-
cle thickness measuring between 3.0 and 4.0 mm
may be considered borderline and require repeat US
a ew days later i the clinical suspicion remains high.
Figure 64-1 shows that the gallbladder is an impor-
tant anatomic landmark, with the pylorus o en
ound nearby. T e most common reason or inabil-
ity to visualize the pylorus is gastric overdistention,
which displaces the pylorus dorsally.
2. D. In ants, i they present with electrolyte abnor-
malities, present with hypochloremic, hypokalemic,
metabolic alkalosis, and paradoxical aciduria. T ese
in ants have gastric acid loss rom emesis, renal loss
o potassium, and renal retention o bicarbonate.
It is important to correct their abnormalities, spe-
ci cally dropping bicarbonate levels to less than 30
mEq/L prior to going to the operating room in order
to avoid intraoperative and postoperative apnea. T e
chloride level should be corrected to at least 90 to
95 mEq/L. Various intravenous f uid regimens have
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C H AP TER 6 4 P y l o Ri C S TEn o S i S 233
Figure 64-1 Surgeon-per ormed US o IHPS. T e muscle
thickness (5.4 mm) and channel length (22.6 mm) are mea-
sured. GB indicates gallbladder; St = stomach; L = liver; D =
duodenum. Reprinted rom Journal o Pediatric Surgery
vol 44, Copeland D.R. et al., Return o the surgeon in the
diagnosis o pyloric stenosis 11891192, Copyright 2009, with
permission rom Elsevier.
been described in the literature. ypically a 5% dex-
trose in 0.45 normal saline with 20 mEq/L o potas-
sium has been most commonly used ollowing a
saline bolus o 2030 mL/kg. Indirect hyperbiliru-
binemia also occurs in a small percentage o in ants
with IHPS. However, this invariably resolves post-
operatively, so urther evaluation at presentation is
unnecessary. It is important to note that the majority
o in ants now present with normal laboratory values,
and earlier diagnosis has led to ewer in ants with
electrolyte abnormalities.
3. A. T e Ramstedt pyloromyotomy remains the opera-
tion o choice, whether open or laparoscopic. An
adequate pyloromyotomy is achieved when the sub-
mucosa bulges into the myotomy site and the edges
o the pyloric muscle are reely mobile. Figure 64-2
demonstrates an adequate pyloromyotomy, with vis-
ualization o bulging submucosa.
4. B. T e exact etiology o IHPS is unknown and is
thought to be multi actorial. T e relative contributions
o genetic and environmental actors and how they
interact to cause the pylorus to hypertrophy during
early in ancy is unknown. T ough environmental
actors are associated with IHPS, the most commonly
accepted pathogenesis is decreased neuronal nitric
oxide. Nitric oxide is a mediator o relaxation in the
234 G En ERAl S U RG ERy EXAM i n ATi o n An D Bo ARD REVi EW
Figure 64-2 Intraoperative photograph o a completed pylo-
romyotomy. T e submucosa can be seen in the depths o the
myotomy.
digestive tract. It is thought that the lack o nitric
oxide synthase in the pyloric tissue causes pylor-
spasm and subsequent hypertrophy. T is has been
demonstrated in pyloric biopsies. Almost all patients
with pyloric stenosis are not born with a hyper-
trophic pylorus. T ough amilial aggregation studies
and twin reports point to a genetic involvement in
the etiology o IHPS, the exact heritability remains
unclear. Males are a ected 4 to 5 times more than
emales, but there is no clear explanation or this di -
erence. No di erences in testosterone levels between
IHPS patients and age-matched controls were ound
in a study o umbilical cord blood testing, and
X-linked transmission patterns have not been shown
to explain why IHPS occurs more in males. Breast-
eeding has been indicated as a potentially protective
actor but bottle- eeding is not a direct cause or etiol-
ogy o IHPS.
5. B. T e most common intra-operative complication
is per oration. A distal per oration can be prevented
by not carrying the distal part o the myotomy past
the pyloric vein o Mayo. T e incidence o duodenal
per oration when pyloromyotomy was per ormed
by general surgeons was ound to be almost 4 times
that o pediatric surgeons (relative risk 3.65; 95% CI
1.439.32). However, when adjusted or surgical vol-
ume this was not signi cant. In a large series o 1777
in ants only 4 required repeat surgery because o an
incomplete pyloromyotomy. General surgeons have
an overall higher complication rate when compared
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to pediatric surgeons (4.18% vs. 2.58%), though not
statistically signi cant.
T ere was a small (0.87%) but statistically sig-
ni cant increase in the incidence o incomplete
pyloromyotomy in the laparoscopic vs. open group.
In order to avoid an incomplete pyloromyotomy an
incision length o 2 cm should be used. In a rand-
omized control trial 200 patients underwent laparo-
scopic versus open pyloromyotomy. 2 patients in the
laparoscopic group and 4 patients in the open group
had post-operative wound in ections, not statistically
signi cant. Post-operative emesis is expected and is
not a complication. Greater than 90% o patients in
a series o 778 vomited or 1 to 3 days a er surgery,
and this is considered to be normal post-operatively.
T e vomiting is thought to be secondary to gastroe-
sophageal ref ux, discoordination o gastric peristal-
sis, or gastric atony. However, i requent vomiting
persists past 3 days, then an incomplete myotomy or
a per oration needs to be considered.
BIBLIOGRAPHY
Copeland DR, Cosper GH, McMahon LE, et al. Return o the
surgeon in the diagnosis o pyloric stenosis. J Pediatr Surg.
2009;44(6):118992; discussion 1192.
Ein SH, Masiakos P , Ein A. T e ins and outs o pyloromy-
otomy: What we have learned in 35 years. Pediatr Surg Int.
2014;30(5):467480.
Hall NJ, Simon E, Seims A, et al. Risk o incomplete pyloromy-
otomy and mucosal per oration in open and laparoscopic
pyloromyotomy. J Pediatr Surg. 2014;49(7):10836.
Krogh C, Biggar RJ, Fischer K, Lindholm M, Wohl ahrt J,
Melbye M. Bottle- eeding and the risk o pyloric stenosis.
Pediatrics. 2012;130(4):e9439.
Langer JC, o . Does pediatric surgical specialty train-
ing a ect outcome a er ramstedt pyloromyotomy? A
population-based study. Pediatrics. 2004;113(5):13427.
Leaphart CL, Borland K, Kane D, Hackam DJ. Hypertro-
phic pyloric stenosis in newborns younger than 21 days:
Remodeling the path o surgical intervention. J Pediatr
Surg. 2008;43(6):9981001.
McAteer JP, Ledbetter DJ, Goldin AB. Role o bottle eeding in
the etiology o hypertrophic pyloric stenosis. JAMA Pedi-
atr. 2013;167(12):11439.
Niedzielski J, Kobielski A, Sokal J, Krakos M. Accuracy o
sonographic criteria in the decision or surgical treatment
in in antile hypertrophic pyloric stenosis. Arch Med Sci.
2011;7(3):50811.
Ostlie DJ, Woodall CE, Wade KR, et al. An e ective pyloromy-
otomy length in in ants undergoing laparoscopic pyloro-
myotomy. Surgery. 2004;136(4):82732.
Peters B, Oomen MW, Bakx R, Benninga MA. Advances in
in antile hypertrophic pyloric stenosis. Expert Rev Gastro-
enterol Hepatol. 2014;8(5):53341.

Sato , Oldham K . Chapter 107. Pediatric abdomen. In:
Mulholland MW, Lillemoe KD, Doherty GM, Maier RV,
Simeone DM, Upchurch GR, eds. Greenf elds surgery: Scien-
tif c principles and practice. 5th ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2011:18851946.
Schwartz MZ. Chapter 78. Hypertrophic pyloric stenosis.
In: Coran AG, Caldamone A, Adzick NS, Krummel M,
Laberge J, Shamberger R, eds. Pediatric surgery. 7th ed.
Philadelphia, PA: Elsevier; 2012:10218.
St Peter SD, Holcomb GW, Calkins CM, et al. Open ver-
sus laparoscopic pyloromyotomy or pyloric stenosis: A
http://surgerybook.net/
C H AP TER 6 4 P y l o Ri C S TEn o S i S 235
prospective, randomized trial. Ann Surg. 2006;244(3):
36370.
utay GJ, Capraro G, Spirko B, Garb J, Smithline H. Electrolyte
pro le o pediatric patients with hypertrophic pyloric ste-
nosis. Pediatr Emerg Care. 2013;29(4):4658.
Vanderwinden JM, Mailleux P, Schi mann SN,Vanderhaeghen JJ,
De Laet MH. Nitric oxide synthase activity in in antile hyper-
trophic pyloric stenosis. N Engl J Med. 1992;327(8):51115.
Ward E, Easley D, Pohl J. Previously unsuspected in antile
hypertrophic pyloric stenosis diagnosed by endoscopy. Dig
Dis Sci. 2008;53(4):9468.
 65
Hirschsprungs Disease

Mary J. Edwards

1. A newborn male in ant has di culty eeding the C. Cystic brosis

rst day o li e. T is progresses to abdominal D. Duodenal atresia
distension and bilious vomiting. T e ollowing E. Intestinal malrotation
plain X-ray is obtained on the second day o li e.
2. T e ollowing contrast enema is obtained:

T is diagnosis:
A. Requires tissue biopsy
B. Requires surgery prior to resumption o oral
eeds
T e di erential diagnosis includes which o the C. Is not associated with chromosomal anomalies
ollowing: D. ypically has a amily history o similar prob-
A. Situs inversus lems on the athers side
B. Pyloric stenosis E. Is cured with a success ul surgery

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3. echnical considerations o the corrective surgery
or Hirschprungs disease include:
A. aking multiple biopsies to determine exactly
when the rst ew ganglion cells are seen, in
order to resect as little colon as possible
B. Resection rom the level o the dentate line to the
ganglionated intestine
C. Routinely per orming a protective colostomy or
ileostomy
D. A tension ree anastomosis
4. A 5-year-old patient who underwent a pull
through or Hirschprungs as a newborn and did
well or years, now presents with a 6 month history
o abdominal distension and ecal incontinence.
T e most likely diagnosis is:
A. Sphincter injury at the time o surgery
B. ransition zone pull through at the time o
surgery
C. Hirschprungs associated enterocolitis
D. Constipation
E. Anastomotic stricture
5. A 6-month-old patient with Downs syndrome
and Hirschprungs disease underwent a leveling
colostomy (at the level o normal ganglionated
bowel) shortly af er birth, ollowed by pull-
through one month ago. He presents now with
ever, lethargy, abdominal distension, and bilious
vomiting. Plain lms reveal no ree air, but multiple
dilated loops o bowel. Rectal exam results in an
explosive output o bloody stained, oul smelling
stool. Which o the ollowing is required or the
management o this patient?
A. C scan to evaluate or intrabdominal abscess
B. Immediate surgical intervention or a revision o
the pull-through
C. Lavage o saline through the anus
D. Blood trans usion
E. Nasogastric decompression
ANSWERS
1. C. T e lm is consistent with a distal intestinal
obstruction. T e di erential diagnosis or this in the
newborn period includes cystic brosis, incarcerated
inguinal hernia,, small le colon syndrome, meco-
nium ileus, meconium plug syndrome, Hirschsprungs
disease, imper orate anus, and ileal or colonic atresia.
In a stable patient without peritonitis the evalua-
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C H AP TER 6 5 H i Rs C H s P Ru n g s D i s EAs E 237
tion begins with a good physical exam. Patients with
imper orate anus or hernias should be diagnosed
readily at this time. Patients with Hirschsprungs dis-
ease will o en have explosive output o stool ollow-
ing rectal exam. T e next diagnostic test should be a
contrast enema with either isotonic or mildly hyper-
tonic water soluble contrast. T is is typically thera-
peutic and diagnostic or small le colon syndrome,
meconium plug, and meconium ileus.
It is o en (75%) diagnostic o Hirschsprungs
disease with correct identi cation o the transition
zone. Findings o a microcolon without obstruction
is very consistent with an ileal atresia. Plain lm nd-
ings o malrotation can be normal, consistent with an
ileus, or a proximal obstruction. Duodenal atresia on
a plain lm classically presents with a double bub-
ble sign that shows air in the duodenum and stom-
ach. Pyloric stenosis would most likely look normal
on plain lm.
2. A. T e enema is consistent with a diagnosis o
Hirschprungs disease with a transition zone in the
rectosigmoid area. While contrast enema is accurate
approximately 75% o the time, tissue diagnosis or
anorectal manometry are the only ways to de ni-
tively make the diagnosis. Anorectal manometry is
not practical in the newborn period, but is a use ul
study in older children or adults. A suction rectal
biopsy at the bedside can sample the submucosa in
an in ant and does not require anesthesia or sedation.
Hirschsprungs disease is due to arrest o the caudal
descent o ganglion cells which coordinate intestinal
relaxation. Aganglionic bowel does not relax properly
to allow propagation o intestinal contents and thus
causes a unctional obstruction. T e biopsy should
sample the submucosa 1 to 2 cm above the dentate
line.
Findings o a lack o ganglion cells and nerve
trunk hypertrophy are diagnostic. Patients with tran-
sition zones in the rectosigmoid can usually be tem-
porized by rectal irrigations which allows or delayed
surgical correction at several months o age, although
surgery in the newborn period is also an acceptable
treatment strategy. Most cases o Hirschprungs dis-
ease are sporadic, although some are amilial. Several
genes have been implicated, most notably the ret
proto-oncogene. Hirschprungs has a strong associa-
tion with Downs syndrome, Waadenburg-Shah, and
others. Even patients who have success ul surgeries
have a high likelihood o ecal soiling (60%) and
238 g En ERAL s u Rg ERY EXAM i n ATi O n An D BO ARD REVi EW
constipation requiring chronic laxative use (30%) in
the long term. Surgery essentially converts the dis-
ease to ultrashort segment Hirschsprungs while tak-
ing away the rectal reservoir.
3. D. Multiple intraoperative biopsies are required, but
in order to avoid pull-through o the transition zone
(where the bowel transitions rom ganglionated to
aganglionated), a level where plenti ul ganglion cells
are seen and no nerve trunk hypertrophy is present
is the goal. Some authors advocate resection up to 10
to 12 cm above this level to more de nitively ensure
normal bowel is pulled through. It is critical to begin
the dissection at least 0.5 to 1.0 cm above the dentate
line in a newborn or 1.0 to 2.0 cm in an older child to
preserve the anal canal and allow uture continence.
A protective ileostomy or colostomy is not typically
done unless there is a technical concern about the
anastomosis. T e surgical principles o per orming
a tension ree, well vascularized anastomosis should
always be ollowed.
4. D. Persistent obstructive symptoms ollowing a
pull-through are not uncommon and all o the
answers listed are possibilities. However, a patient
that has done well or years and suddenly presents
with distension and ecal soiling is likely to be con-
stipated. T irty to eighty- ve percent o patients with
Hirschprungs disease will have constipation ollow-
ing pull-through that may require chronic laxatives,
and 60% to 75% will have intermittent ecal soiling.
Fecal soiling tends to become worse during periods
o severe constipation. T ese patients are best evalu-
ated with a physical exam and a plain X-ray. I these
are consistent with constipation then a clean out with
enemas or oral laxatives can be initiated and inconti-
nence will likely improve. Persistent obstruction a er
appropriate management or no signi cant improve-
ment a er pull-through should be evaluated with
contrast enema, exam under anesthesia and repeat
rectal biopsy.
5. C. T is patient has Hirschprungs associated enter-
ocolitis (HEC). Risk actors or this condition are
Downs syndrome, diagnosis a er one week o li e,
anatomic obstruction, and a history o previous HEC.
Obstruction can be a result o an anastomotic stric-
ture, swelling o the anastomosis in the early postop
period and transition zone pull-through. However,
HEC can also occur in the absence o these compli-
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cations. T is is one o the most eared complications
o Hirschsprungs, as i treatment is not initiated
quickly patients may become severely ill and die. T e
etiology is bacterial translocation through the wall o
the colon, presumably due to an ine ective mucosal
barrier in the colon. reatment involves uid resus-
citation, antibiotics, nutritional support and most
importantly, rectal irrigations. T is is done transan-
ally with warm saline. Unlike an enema, a catheter is
used to evacuate stool and gas, while gently irrigat-
ing stool out o the colon. In severe cases, colostomy
may be required. Patients can present with HEC
both be ore and up to 2 years a er pull-through. T is
clinical presentation is much more consistent with
enterocolitis than an abscess. A C scan is not typi-
cally utilized to evaluate or intra-abdominal abscess
in in ants. T e lack o intra-abdominal at makes
it dif cult to discern an abscess cavity rom a uid
lled loop o bowel. I imaging is needed to evaluate
or this, ultrasound is typically a better study. Neither
blood trans usions or nasogastric decompression is
required or treatment but they may be utilized.
BIBLIOGRAPHY
DeLa orre L, Langer JC. ransanal pullthrough or
Hirschsprung Disease: echnique, controversies, pearls,
pit alls and an organized approach to the management o
postoperative obstructive symptoms. Sem Ped Surg. 2010;
19:96106.
Engum SA, Gros eld JL. Long- erm results o treatment o
Hirschsprungs Disease. Sem Ped Surg. 2004;13;27385.
Haricharan RN, Georgeson KE. Hirschprung disease. Sem Ped
Surg. 2008;17:26675.
Kapur RP, Kennedy AJ. ransition Zone pull through: surgical
pathology considerations. Sem Ped Surg. 2012;21:291301.
Langer JC. Hirschsprungs Disease. In: Oldham K , Colom-
bani PM, Foglia RP, Skinner MA, eds. Principles and
Practice of Pediatric Surgery, 2nd ed. Philadelphia, PA:
Lippincott Williams and Wilkins: 2005:134764.
Levitt MA, Dickie BA, Pena A. Evaluation o the patient with
Hirschprung disease who is not doing well a er a pull
through procedure. Sem Ped Surg. 2010;19:14653.
Mundt E, Bates MD. Genetics o Hirschprung disease and
anorectal mal ormations. Sem Ped Surg. 2010;19:10117.
Mychaliska GB. Introduction to Neonatal Intestinal Obstruc-
tions. In: Oldham K , Colombani PM, Foglia RP, Skinner
MA, eds. Principles and Practice of Pediatric Surgery, 2nd ed.
Philadelphia, PA: Lippincott Williams and Wilkins: 2005:
12221226.
Rintala RJ, Pakarinen MP. Long term outcomes o
Hirschprungss disease. Sem Ped Surg. 2012;21:33643.
Vieten D, Spicer R. Enterocolitis ollowing Hirschprungs Dis-
ease. Sem Ped Surg. 2004;13:26372.
 66
Omphalocele/Gastroschisis

Paul Wetstein

You are called to the delivery room to assist in man- 3. Which of the following is the most important
agement o the delivery o a child with a known aspect regarding the management of a newborn
anterior abdominal wall de ect and maternal polyhy- with omphalocele?
dramnios. A. Protection o the sac to help prevent heat loss
and insensible uid loss
1. Regarding the pathophysiology of pediatric B. Establishing IV access
abdominal wall defects, which of the following is C. Gastric (OG) tube placement or bowel decom-
correct? pression
A. Polyhydramnios and intestinal atresia are not D. Airway stabilization
associated with omphalocele or gastroschisis. E. Attempting to primarily repair all de ects
B. Gastroschisis is commonly associated with cardiac
and chromosomal anomalies. 4. Which of the following is correct regarding the
C. A giant omphalocele is more likely to be associ- management of a newborn with gastroschisis?
ated with etal aneuploidy than gastroschisis. A. An associated mid-gut volvulus is not a concern.
D. Intestinal nonrotation is not associated with gas- B. Sequential closures should be avoided.
troschisis or omphalocele. C. T e bowel tends to be less damaged than that o
E. Herniated liver indicates the de ect is most likely the omphalocele.
a omphalocele. D. Surgical management is urgent.
E. T e associated abnormalities are the bigger
2. Which of the following associations is correct concern.
regarding congenital abdominal wall defects?
A. Since gastroscisis is commonly ound o to the 5. Omphalocele is associated with many syndromes
midline, liver is o en seen herniating through like Beckwith-Wiedemann, the pentalogy of
the de ect. Cantrell, and CHARGE. Which of the following is
B. T e most important prognostic actor or a component of the pentalogy of Cantrell?
gastroscisis is the amount o bowel herniated. A. Coloboma
C. T e most important prognostic actor or ompha- B. Gigantism
locele is presence o other associated anomalies. C. Ectopic cordis
D. Omphaloceles are usually located at the umbili- D. Genital hypoplasia
cus. E. Ear abnormalities

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240 G EN ERAL S U RG ERY EXAM I N ATIO N AN D BO ARD REVI EW

ANSWERS sequential reduction and staged closure with a silo or

1. E. Be ore 12 weeks o gestation, the di erentiation
o an omphalocele and a physiologic midgut hernia-
tion cannot be made in the absence o herniated liver.
Herniated liver appreciated on prenatal ultrasound
is not a normal physiologic f nding. Intestinal atre-
sia is associated with gastroschisis in 10% to 20%
o cases. Omphalocele has also been reported to be
associated with intestinal atresias. Omphalocele has
been associated with structural anomalies, chro-
mosomal anomalies, and several syndromes. Small
omphalocele sacs with an intracorporeal liver have
a stronger association with chromosomal anomalies
than larger de ects.
other alternative.
4. D. While one should be cautious in preserving the
omphalocele sac, extreme caution should be main-
tained when handling the bowel in gastroschisis
because there is no sac. In gastroschisis patients,
the bowel may be extremely edematous and riable.
It may also be malrotated and prone to becoming a
volvulus. Under most circumstances, gastroschisis
intestines are placed in a warm saline f lled plas-
tic organ bags, secured at the nipple line. An initial
care ul attempt and reduction and operative closure
is warranted by a trained surgeon, but a sequential
reduction and staged closure may be necessary.

5. C. T e pentalogy o Cantrell is comprised o ompha-

2. D. Giant omphalocele is associated with herniated locele, ectopia cordis, intracardiac de ect, sternal cle ,
liver. Di erentiating characteristics between gastro- and an anterior diaphragmatic hernia. Beckwith-
schisis and omphalocele are summarized in able 66-1 Weidemann syndrome composes o an umbilical de ect
below. which could be either a hernia or an omphalocele, mac-
roglossia and gigantism. Coloboma (C) is a component
3. A. Initial resuscitation centers around ensuring o the CHARGE syndrome which also includes (H)
a stabilized airway, uid resuscitation, intestinal Heart Disease, (A) atresia choanae, (R) retarded growth,
decompression via gastric tube, IV antibiotics, and development and/or CNS anomalies, (G) genital hypo-
preventing heat and insensible uid loss. Protection plasia, (E) ear anomalies and/or dea ness.
o the sac is imperative. Some advocate or wrapping
the bowel in thermoneutral, sterile saline soaked
gauze and covering with a bowel bag. Primary clo- BIBLIOGRAPHY
sure o small and medium sized de ects is pre erred Chung DH. Pediatric Surgery. In: ownsend Jr. CM, Beau-
but attempts at closure o larger de ects will need a champ RD, Evers BM, Mattox KL. Sabiston extbook of
Surgery: T e Biological Basis of Modern Surgical Practice.
19th ed. Philadelphia, PA: Elsevier Saunders;2012:
Curtis JA, Watson L. Sonographic diagnosis o omphalocele
Table 66-1 DIFFERENTIATING CHARACTERISTICS in the f rst trimester o etal gestation. J Ultrasound Med.
BETWEEN OMPHALOCELE AND GASTROSCHISIS 1988;7:97.
Dono rio M , Moon-Grady AJ, Hornberger LK, Copel JA,
Characteristic Omphalocele Gastroschisis Sklansky MS, Abuhamad A, et al. on behal o the American
Heart Association Adults with Congenital Heart Disease
Herniated Bowel liver Bowel only Joint Committee o the Council on Cardiovascular Disease
viscera in the Young and Council on Clinical Cardiology, Coun-
Sac Present Absent cil on Cardiovascular Surgery and Anesthesia, and Coun-
cil on Cardiovascular and Stroke Nursing. Diagnosis and
Associated Common (50%) Uncommon
treatment o etal cardiac disease: A scientif c statement
anomalies (< 10%)
rom the American Heart Association. Circulation. May 27,
Location o Umbilicus Right o 2014;129(21):2183242. doi: 10.1161/01.cir.0000437597.
de ect umbilicus 44550.5d. Epub April 24, 2014.
Mode o delivery Vaginal/cesarean Vaginal Kitchanan S, Patole SK, Muller R, Whitehall JS. Neonatal out-
come o gastroschisis and exomphalos: A 10-year review.
Surgical Nonurgent Urgent J Paediatr Child Health. 2000;36(5):428.
management Klein MD. Congenital De ects o the Abdominal Wall. In:
Prognostic Associated Condition o Coran AG, Caldamone A, Adzick NS, Krummel M,
actors anomalies bowel Laberge JM, and Shamberger R, eds. Pediatric Surgery.
7th ed. Philadelphia, PA: Elsevier Saunders; 2012:

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 C H AP TER 6 6 O M P H ALO C ELE/ G AS TRO S C H IS I S 2 41

Nyberg DA, Fitzsimmons J, Mack LA, Hughes M, Pretorius
DH, Hickok D, et al. Chromosomal abnormalities in etuses
with omphalocele. Signif cance o omphalocele contents.
J Ultrasound Med. 1989;8(6):299.
Pagon RA, Graham JM Jr, Zonana J, Yong SL. Coloboma, con-
genital heart disease, and choanal atresia with multiple
anomalies: CHARGE association. J Pediatr. August 1981;
99(2):2237.
Snyder CL, Miller KA, Sharp RJ, Murphy JP, Andrews WA,
Holcomb III GW, et al. Management o intestinal atre-
sia in patients with gastroschisis. J Pediatr Surg. October
2001;36(10):1542154.

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r auma Sur ger y a nd Cr it ic a l
Ca r e
Matthew J. Martin

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 67
rauma and Critical
CareRoadside Bomb
M h wE k M h w J. M

During the annual Memorial Day parade o your home-

town, a large explosion occurs along the parade route, with
multiple injured persons and atalities at the scene. Pre-
hospital EMS providers, rst responders, and bystanders
begin to administer rst aid to those injured and start
trans er o patients to the local hospital. As an on-call
general surgeon, you and your colleagues stand ready in
the emergency department while preparing or a potential
mass casualty event. Hospital administrators have acti-
vated the disaster/mass casualty plan, triage o cers are
designated, and the incident command plan is in e ect.

1. A p -hosp p ov o s j
w h b ow k p o
p wo s w h
bo b h (F 67-1). T f s p o
h o h sp sho b ?
A. Airway
B. Breathing
C. Circulation/control o li e-threatening hemor-
rhage
D. Disability
E. Evacuation
Figure 67-1 Representative injury pattern o roadside bomb
2. Wh h o h o ow p so h o h so or improvised explosive device.
p s o ? E. Intra-cranial hemorrhageReversal o hyperco-
A. Junctional hemorrhage ourniquet placed aguable state and neurosurgical intervention
directly over the injury
B. Extremity hemorrhageHemostatic dressing 3. T p p so o o s
and direct pressure wh h o h o ow ?
C. runcal hemorrhagePermissive hypotension A. Primary ocus upon control o hemorrhage only
and hemostatic resuscitation B. Avoiding the use o temporary abdominal clo-
D. Pelvic hemorrhageEarly use o rFactor VIIa sures

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246 G EN ERAL S U RG ERY EXAM IN ATI O N AN D BO ARD REVIEW
C. Appropriate triage based upon injuries and avail-
able resources
D. Colostomy or all colon injuries
E. De nitive repair o all abdominal injuries
4. T o p o o o o h os
s s o s wh h o h o ow ?
A. Limited use o colloid solution resuscitation
B. 3:1:1 PRBC:FFP:Platelet trans usion strategy
C. Empiric trans usion o cryoprecipitate
D. Administration o tranexamic acid ( XA) or
treatment o hyper brinolysis
5. P b s j s wh h o h proximal on the injured extremity and later moved
o ow ? distally. Approximately one-third o bleeding deaths
A. Damage to gas lled organs due to extreme pres-
sure changes
B. runcal injury sustained as victim is thrown
through the air by blast
C. Crush injuries rom structural collapse around
the patient
D. Penetrating injury rom debris and ragments
propelled by the blast orce
ANSWERS
1. C. raditional teaching o advanced cardiac li e
support (ACLS) and advanced trauma li e support
(A LS) concepts stress the ABCDE mantra (air-
way, breathing, circulation, disability, and exposure),
in which airway control is paramount. However, in
the setting o combat injuries and civilian catastro-
phes such as blast injuries, immediate control o
li e-threatening hemorrhage takes precedence as
atal hemorrhage can rapidly occur while addressing
other elements o the primary survey. Hemorrhage
remains the leading cause o potentially preventable
morbidity and mortality in both military and civilian
trauma, rein orcing the importance o pre-hospital
e orts to control bleeding and prevent exsanguina-
tion a er severe injury. T e experiences gained dur-
ing combat operations in Iraq and A ghanistan have
led to a change in the priorities o treatment that are
taught to combat medics and rst-responders.
As the most likely cause o potentially preventable
death in these scenarios is hemorrhage, the standard
A LS approach o ocusing rst on the airway has
been changed to a primary ocus on C, or the control
o hemorrhage, as the rst priority. T e next priori-
ties would be on assessing the airway and breathing
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or li e-threatening issues such as airway obstruction,
tension pneumothorax, or an open pneumothorax
(sucking chest wound).
2. C. Major extremity hemorrhage can be e ectively
controlled in both the pre-hospital and hospital set-
ting using an e ective proximal tourniquet. Appli-
cation o tourniquets to control major hemorrhage
should be placed as distal as possible yet proximal to
the site o injury, to control hemorrhage and limit the
extent o tissue ischemia. Hasty tourniquets applied
in combat under re or prior to moving a patient to
a sa er location may be placed expediently anywhere
a er explosive events are due to extremity hemor-
rhage, with the remaining two-thirds attributed
to junctional bleeding or non-compressible trun-
cal hemorrhage (Figure 67-2). Junctional injuries
are de ned as injuries to the groin, axilla, neck, or
perineum. T ese injuries present major challenges
to hemorrhage control as damaged deep vascular
structures transition rom the extremities to major
cavities beyond the e ective reach o a proximal
tourniquet. Direct pressure and topical hemostatic
adjuncts are o en the only currently available treat-
ments o potential bene t be ore proximal surgical
control can be achieved. Non-compressible trun-
cal hemorrhage is the most eared and atal type o
bleeding as it is not amenable to pre-hospital hem-
orrhage control measures, and requires higher-level
interventions such as surgery or angioembolization.
Signi cant pelvic hemorrhage may result rom
complex bony injuries and damage to the pelvic vas-
culature. reatment o pelvic ractures may include
pelvic sheeting, commercial or improvised binders,
and orms o external xation, that aim to stabilize
the pelvic ring. Surgical control o pelvic hemorrhage
Figure 67-2 Distribution o preventable bleeding deaths
rom battle eld wounds by the site o hemorrhage.
 C H AP TER 6 7 TRAU M A AN D C RI TI C AL C ARE RO AD S ID E BO M B
includes open and catheter based therapies as well
as pre-peritoneal pelvic packing to tamponade hem-
orrhage. Permissive hypotension is the concept that
avoiding normal or elevated blood pressure in a
bleeding patient prior to surgical hemorrhage con-
trol limits blood loss.
T e goal is to maintain an adequate arterial pres-
sure or critical organ per usion while limiting over-
pressurization rom vigorous f uid resuscitation that
may exacerbate hemorrhage. Although there was
initial interest in the use o activated recombinant
actor VII (rFactor VIIa) as an adjunctive therapy
or bleeding, subsequent studies have ound little to
no bene t and it also would not be used as a pre-
hospital therapy or pelvic bleeding. T e treatment
o traumatic intracranial hemorrhage begins with
reversal o any identi ed coagulopathy, not hyperco-
aguble state, treatment o associated cerebral edema,
and possible neurosurgical interventions.
3. C. Damage control surgery (DCS) is a concept that
includes the principles o limiting urther physi-
ologic insult to a severely injured patient through the
rapid surgical control o li e-threatening hemorrhage
and enteric spillage, to minimize urther bleeding,
restore tissue per usion, and prevent sepsis. T e goal
is to avoid prolonged, initial operative procedures
that may urther exacerbate hypothermia, coagu-
lopathy, and/or acidosis. emporary closures o the
abdomen and thorax may be employed to shorten
the procedure length and allow or urgent or planned
re-operation in this population. Once bleeding and
gastrointestinal spillage are controlled, there are no
urther attempts to address other non-li e-threatening
abdominal injuries at the initial surgery.
T e operation is terminated and the patient is
returned to the ICU or resuscitation and restoration
o normal physiology and coagulation. Following
physiologic restoration these patients are taken back
to the operating room or de nitive treatments and
closure. In mass casualty situations and resource-
constrained environments, DCS allows limited
surgical personnel to provide critical surgical proce-
dures to severely injured patients rapidly, and then
either evacuate them to higher levels o care or clear
the operating room or additional patients.
4. D. Damage control resuscitation (DCR) or hemo-
static resuscitation is the concept o limiting urther
blood loss be ore surgical hemorrhage control is
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247
obtained, as well as replacing shed-blood volume
with a balanced blood product based resuscitation
that restores the capacity to carry and deliver oxygen
and addresses derangements o the coagulation sys-
tem. DCR research has ocused upon improved mor-
bidity and mortality with limitation o crystalloid
in usion to prevent hemodilution (colloid solutions
are, in general, not advocated or trauma resusci-
tations), acidosis and worsening o coagulopathy,
in avor o trans usion ratios approaching 1:1:1 o
packed red blood to resh rozen plasma and plate-
lets. Additional targeted treatment o speci c coagu-
lation abnormalities based upon traditional studies
(P /INR, P , brinogen) and point o care test-
ing such as thromboelastography is recommended,
to avoid unnecessary trans usion and appropriate
resource utilization.
Permissive hypotension is the concept that avoid-
ing normal or elevated blood pressure in a bleeding
patient prior to surgical hemorrhage control limits
blood loss. T e goal is to maintain an adequate arterial
pressure or critical organ per usion while limiting
over-pressurization rom vigorous f uid resuscitation
that may exacerbate hemorrhage. Previous studies in
civilian trauma patients have con rmed a avorable
survival advantage by limiting pre-hospital resuscita-
tion but heterogeneity in clinical trials such as opti-
mal blood pressure target and f uid resuscitation type
have yet to yield de nitive conclusions.
Current research has identi ed early derange-
ments o the coagulation system that appear to con-
er an increased risk o morbidity and mortality a er
trauma, termed the acute coagulopathy o trauma.
Hyper brinolysis is a key component o this condi-
tion, and targeted pharmacologic intervention with
the anti brinolytic agent, tranexamic acid ( XA),
has been linked to a survival advantage in several
studies o bleeding trauma patients. T e use o XA
in the setting o major hemorrhage and massive
trans usion situations is now recommended in the
early treatment (< 3 hours rom injury) in civilian
and combat injuries.
5. A. Blast injuries are traditionally classi ed based
upon the discrete mechanism o injury involved.
Primary blast injuries involve damage to gas- lled
organs such as the intestine, lungs, and middle ear
as well as the brain. T ese injuries result rom over-
pressurization due to the blast orce. Rupture o the
tympanic membrane is a requently encountered
248 G EN ERAL S U RG ERY EXAM I N ATIO N AN D BO ARD REVI EW
primary blast injury, but the absence does not rule out
other types o blast injury. Secondary blast injuries
result rom injury due to f ying debris and ragments
that are propelled by the blast. T ese are the most re-
quently sustained type o blast injuries. ertiary inju-
ries occur when a person is thrown through the air by
the blast, while Quaternary injuries include other blast
e ects such as burn injury, inhalation o toxic gases, or
injury due to collapse o structures around the person.
Lastly, quinary injuries are the result o contamination
by chemical, radiologic, or biologic materials rom the
blast itsel or other injured persons.
In addition to the injury classi cation described
above, the severity o injury sustained a er a blast
mechanism depends upon the patients proximity to
the blast, the energy o the blast itsel , and whether
or not the blast occurred in a closed space. Persons
injured by a blast in an enclosed space such as a
vehicle or building requently sustain a higher rate
o lethal primary blast injury as well as increased re-
quency o secondary penetrating injuries.
BIBLIOGRAPHY
Beekley AC. Damage control resuscitation: a sensible
approach to the exsanguinating surgical patient. Crit Care
Med. 2008;36(7):S26774.
Blackbourne LH. Combat damage control surgery. Crit Care
Med. 2008;36(7):S30410.
Borgman MA, Spinella PC, Perkins JG, et al. T e ratio o
blood products trans used a ects mortality in patients
receiving massive trans usions at a combat support hospi-
tal. J Trauma. 2007;63(4):80513.
Bulger EM, Snyder D, Schoelles K, et al. An evidence-based
guideline or external hemorrhage control: American col-
lege o surgeons committee on trauma. Prehosp Emerg
Care. 2014;18(2):16373.
Butler FK Jr, Holcomb JB, Giebner SD, et al. actical combat
casualty care 2007: Evolving concepts and battle eld expe-
rience. Mil Med. 2007;172(11):S1S19.
http://surgerybook.net/
Cooper GJ, Maynard RL, Cross NL, et al. Casualties rom ter-
rorist bombings. J Trauma. 1983;23(11):95567.
Cothren CC, Osborn PM, Moore EE, et al. Preperitoneal pel-
vic packing or hemodynamically unstable pelvic ractures:
A paradigm shi . J Trauma. 2007;62(4):83439.
Cotton BA, Reddy N, Hatch QM, et al. Damage control resus-
citation is associated with a reduction in resuscitation vol-
umes and improvement in survival in 390 damage control
laparotomy patients. Ann Surg. 2011;254(4):598605.
CRASH-2 trial collaborators, Shakur H, Roberts I,
Bautista R, et al. E ects o tranexamic acid on death, vas-
cular occlusive events, and blood trans usion in trauma
patients with signi cant haemorrhage (CRASH-2): A ran-
domised, placebo-controlled trial. Lancet. 2010;376:2332.
DePalma RG, Burris DG, Champion HR, et al. Blast injuries.
N Engl J Med. 2005;352(13):133542.
Eastridge BJ, Mabry RL, Seguin P, Cantrell J, ops , Uribe P,
et al. Death on the battle eld (20012011): Implications or
the uture o combat casualty care. J Trauma Acute Care
Surg. 2012;73:S4317.
Kauvar DS, Le ering R, Wade CE. Impact o hemorrhage on
trauma outcome: An overview o epidemiology, clinical
presentations, and theraputic considerations. J Trauma.
2006;60:S3S11.
Kwan I, Bunn F, Chinnock P, et al. iming and volume o f uid
administration or patients with bleeding. Cochrane Data-
base Syst Rev. 2003;(3):CD002245.
Morrison CA, Carrick MM, Norman MA, et al. Hypotensive
resuscitation strategy reduces trans usion requirements
and severe postoperative coagulopathy in trauma patients
with hemorrhagic shock: Preliminary results o a random-
ized controlled trial. J Trauma. 2011;70(3):65263.
Morrisson JJ, Dubose JJ, Rasmussen E, et al. Military applica-
tion o tranexamic acid in trauma emergency resuscitation
(MA ERs) study. Arch Surg. 2012;147:1139.
Rommens PM, Ho mann A, Hessmann MH, Management
o acute hemorrhage in pelvic trauma: An overview. Eur J
Trauma Emerg Surg. 2010;2:9199.
Rotondo MF, Schwab CW, McGonigal MD, et al. Damage
control: An approach or improved survival in exsangui-
nating penetrating abdominal injury. J Trauma. 1993;35(3):
37582.
 68
Kni e Wounds
Laura Mazer
A 35-year-old man is brought to the emergency depart-
ment a er an altercation at a bar. He has a 3 cm stab
wound to his right chest, approximately 5 cm lateral to
and just superior to his nipple. He is able to tell you that
the wound is rom a kni e. He is oriented and appropri-
ate, although intoxicated, and complains loudly o pain
in his right chest. His initial vital signs are as ollows:
HR 96, BP 110/63, RR 20, 98% saturation on room air.
1. What is your rst step in the management o this
patient?
A. Per orm a tube thoracostomy.
B. Per orm the primary survey and examine or any
other wounds.
C. Per orm a FAS ( ocused assessment with
sonography or trauma) scan to identi y intra-
abdominal injury.
D. Obtain a chest radiograph to identi y presence o
pneumothorax or hemothorax.
2. Despite luid resuscitation, the patients blood
pressure suddenly becomes 60/palpable. His
trachea is midline and his breath sounds are
reduced over the right hemithorax, with dullness
to percussion. What is the best next step in
management?
A. Place a 36F chest tube into the right pleural cav-
ity at the 2nd interspace in the midaxillary line.
B. Place a 36F chest tube into the right pleural cav-
ity at the 5th interspace in the mid- or anterior
axillary line.
C. Place an 18 g angiocath into the 2nd intercostal
space at the midclavicular line.
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D. ake the patient immediately to the operating
room or thoracotomy.
E. Initiate a massive trans usion protocol to stabi-
lize the patient or computerized tomography
(C ) scan to identi y the source o the hypoten-
sion.
3. Which o the ollowing is a correct indicator or
operative intervention paired with an appropriate
operative approach or this patient?
A. Greater than 500 cc blood rom the chest tube
upon initial placementright posterolateral
thoracotomy in the operating room.
B. Cardiac arrest in the trauma bayle anterolat-
eral thoracotomy in the emergency room.
C. Persistent trans usion requirements to maintain
stable blood pressuremedian sternotomy in
the emergency room.
D. Second entry wound identi ed below the cos-
tal margintransverse anterior thoracotomy
(clamshell incision) in the operating room.
E. An entry wound medial to the midclavicular
linemedian sternotomy in the emergency room.
4. I this patients wound were located in the neck
above the cricoid cartilage (but below the angle o
the mandible), which o the ollowing diagnostic
tests would be de nitely indicated?
A. None; manage expectantly with admission or
serial exams.
B. Computed tomography (C ) o the neck with
C angiography (C A) o the cervical vessels.
C. C A or angiography plus bronchoscopy.
250 G EN ERAL S U RG ERY EXAM I N ATIO N AN D BO ARD REVI EW
D. C A or angiography, bronchoscopy, and esopha-
gogastroduodenoscopy (EGD).
5. T e patient has 800 cc initial drainage rom the
right-sided chest tube, which then slows down
over the next ew hours. He is admitted to the f oor
on telemetry or monitoring, and remains stable.
A ollow up chest radiograph the next morning
demonstrates signi cant residual basilar f uid.
What is the most appropriate next step?
A. Go to the operating room or a video-assisted
thoracoscopic surgery (VA S) to evacuate the
retained hemothorax.
B. Go to the operating room or a right antero-
lateral thoracotomy.
C. Place a pigtail catheter to drain the residual
hemothorax.
D. Observation and serial chest X-rays.
ANSWERS
1. B. In any trauma patient, the rst priority is to ensure
stable A,B,Cs, airway, breathing, and circulation,
which may include emergent interventions (e.g., tube
thoracostomy). In this patient with stable vital signs,
the initial step is to per orm a primary and secondary
surveya brie head to toe physical exam. A common
mistake in the setting o penetrating trauma is ail-
ure to identi y multiple injuries. Common locations
or missed penetrating injuries can be in the back,
axilla, or perineum, so a complete head to toe survey
is critical. Most patients can be stabilized enough to
undergo a secondary survey, but any problems iden-
ti ed on the primary survey should be immediately
addressed. Once all injuries are identi ed, they can be
prioritized or diagnostic imaging or operative repair.
Both chest X-ray and FAS scan can be used as
adjuncts to the secondary survey, but they do not
replace the need or a head-to-toe assessment o the
patient. In the initial evaluation o a trauma patient,
priorities are: 1. identi ying all wounds, 2. determin-
ing i urgent li esaving intervention is indicated, and
3. determining i additional testing is needed.
2. B. In the setting o penetrating trauma to the chest,
the di erential diagnosis or hypotension includes
tension pneumothorax, cardiac tamponade, and
hemothorax. Classically, a tension pneumothorax
will present with deviation o the trachea away rom
the injury, increased percussion and decreased breath
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sounds with distended neck veins. However, these
can be late ndings and may be di cult to appreciate
in a busy and noisy trauma bay. I a tension pneumo-
thorax is suspected, the rst step would be placing
an large bore (14 or 18 gauge) angiocath to needle
decompress the thoracic cavity. T e diagnosis would
be con rmed by a rush o air rom the needle, and a
chest tube should then be placed.
In this patient, the absence o tracheal deviation
along with dullness to percussion makes a hemotho-
rax the more likely diagnosis, and a chest tube the
appropriate next step. T e pre erred method or tube
thoracostomy is to enter the sa e triangle bounded
by the anterior border o the latissimus, the lateral
border o the pectoralis major, and a horizontal line
at the level o the nipple (males) or in ra-mammary
crease ( emales). T is positioning minimizes the
likelihood o entering the abdominal cavity, injur-
ing muscle or breast tissue, or underlying structures
such as the internal mammary artery, and avoids the
major chest wall musculature that can cause signi -
cant pain with chest tube insertion.
3. B. Accepted indications or emergency department
thoracotomy in the setting o penetrating thoracic
trauma are loss o pulses with previously witnessed
cardiac activity and unresponsive, persistent, hypo-
tension. In blunt trauma, indications are rapid exsan-
guination rom the chest tube (> 1500 cc on initial
placement) with unresponsive hypotension. Survival
rates a er emergency thoracotomy are up to 30%
or penetrating trauma, but closer to 1% or blunt
trauma patients. T e goals o an emergency depart-
ment thoracotomy are to control hemorrhage (which
may require cross-clamping the descending thoracic
aorta), allow access or internal cardiac massage, and
treat potential cardiac tamponade. Access to the heart,
descending aorta, and mediastinum requires a le
thoracotomy incision. Regardless o the side o injury,
traumatic arrest warrants a le thoracotomy or access
to the mediastinal structures. I necessary, the incision
can be extended to the right chest (clamshell thora-
cotomy) or access to the right thoracic cavity.
Stable patients with penetrating trauma may still
require exploration in the operating room. radi-
tionally, anterior abdominal stab wounds warranted
mandatory laparotomy to rule out intraabdominal
injury, although recent evidence has raised the possi-
bility o expectant management or the stable patient
with penetrating injuries. T oracic injury to the

box, the area de ned by nipples, sternal notch, and
xiphoid process generally warrants operative explo-
ration as well.
In a stable patient, however, it is reasonable to
proceed with additional diagnostic studies. Although
some have advocated an extensive workup includ-
ing esophagoscopy, bronchoscopy, and a pericardial
window, more recent data indicates that a high-qual-
ity C scan provides excellent imaging o the tho-
rax and mediastinum, and additional studies can be
per ormed based on the clinical exam and C nd-
ings. In a patient who undergoes tube thoracostomy,
indications to proceed to the operating room are:
> 1500 cc on initial placement, > 150200 cc/hr or
> 3 hours, or hemodynamic instability requiring per-
sistent blood trans usions.
4. B. Zone I o the neck extends rom the clavicles to
the cricoid cartilage, Zone II is rom the cricoid car-
tilage to the angle o the mandible, and Zone III is
rom the angle o the mandible to the skull base. T e
majority o penetrating injuries, as with the patient in
this case, occur in Zone II. For unstable patients with
signs o major vascular or airway injury, manage-
ment o penetrating neck trauma involves securing
an airway and proceeding directly to the operating
room or neck exploration. T ese signs include stri-
dor, massive subcutaneous air, gurgling or bubbling
through the wound, hemoptysis/hematemesis, and
pulsatile bleeding or rapidly expanding hematoma.
Historically, all Zone II injuries that breached the
platysma mandated operative exploration. T is is
no longer widely practiced, and stable patients with
no hard signs o vascular or airway imaging can be
managed expectantly with appropriate diagnostic
tests. C A has similar sensitivity to operative explo-
ration or identi ying vascular and so tissue injuries.
C imaging can also provide valuable in ormation
about potential injuries to the esophagus or trachea
that can guide the selective use o additional stud-
ies to evaluate these structures. Esophageal injuries
are requently asymptomatic, and morbidity signi -
cantly increases i repair is delayed beyond 24 hours.
Contrast esophagography or esophagoscopy is rec-
ommended or all Zone II injuries that breach the
platysma and have either physical exam or C scan
ndings concerning or an esophageal injury. Simi-
larly, exible bronchoscopy can be used selectively
based on any exam or C imaging ndings concern-
ing or airway injury.
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C H AP TER 6 8 KN I f E WO U N D S 251
5. A. Retained hemothorax is a relatively common
problem among patients who present with a moder-
ate or large volume hemothorax with either blunt or
penetrating trauma. Although observation only is an
option, this carries the risk o developing an in ected
hematoma (empyema) or brothorax. I there is still
a signi cant amount o clotted blood in the thoracic
cavity that is not adequately drained by the initial chest
tube, then there are several options or management.
T ese include placement o a second chest tube
(or removal and replacement o the initial chest tube)
in a better position to evacuate the uid collection or
administration o local lytic therapy ( PA or uroki-
nase administered through the chest tube) to attempt
to break up the clot and allow drainage through the
chest tube. Although these can be e ective in select
cases, they have been associated with relatively high
ailure rates. Since the retained hemothorax likely
consists o clotted blood, a small-bore pigtail cath-
eter is unlikely to achieve adequate drainage. T ere
has been a trend toward the increased use o early
VA S to evacuate the hematoma and place a well-
positioned chest tube under direct visualization. T is
approach can also be use ul i there is suspicion or
an associated diaphragm injury that can be repaired
simultaneously. Median sternotomy would not be
indicated or evacuation o a retained hemothorax.
BIBLIOGRAPHY
Bif WL, Moore EE. Management guidelines or penetrating
abdominal trauma. Curr Opin Crit Care. December 2010;
16(6):60917.
Brohi K. Emergency Department T oracotomy. Available
at: http://www.trauma.org/index.php/main/article/361/.
Accessed June 9, 2016.
Burgess CA, Dale O , Almeyda R, Corbridge RJ. An evidence
based review o the assessment and management o pene-
trating neck trauma. Clin Otolaryngol. February 2012;37(1):
4452.
Houshian S, Larsen MS, Holm C. Missed injuries in a level I
trauma center. J rauma. April 2002;52(4):71519.
Laws D, Neville E, Du y J. B S guidelines or the insertion o
a chest drain. T orax. May 2003;58(Suppl 2):ii539.
Moore FA, Moore EE. Initial Management o Li e-T reatening
rauma. In: Souba et al., eds. ACS Surgery: Principles
and Practice, 6th ed. Ontario, Canada: B.C. Decker Inc;
2007:121130.
Mowery N , Gunter OL, Collier BR, et al. Practice manage-
ment guidelines or management o hemothorax and occult
pneumothorax. J rauma. February 2011;70(2):51018.
isherman SA, Bokhari F, Collier B, et al. Clinical practice
guideline: penetrating zone II neck trauma. J rauma. May
2008;64(5):13921405.
 69
Penetrating raumaMultiple
Gunshot Wounds
Erik Criman and Matthew J. Martin
You wake to the sound o your pager and the amiliar
re rain overhead, rauma team to the trauma room.
rauma team to the trauma room. Your pager reads:
23YOM GSW O CHES /ABD/R HIGH. GCS
15 HR 100 BP 90/P RR30 98%/NRB. E A 3MIN.
As you reach the trauma bay, your patient arrives in
extremis. He is unresponsive, his breathing is agonal
with oxygen saturation in the low 80s despite ventila-
tion with a bag valve mask, and his radial pulse is weakly
palpable with a rate o 105 beats per minute. Paramedics
have established two large bore peripheral IVs and have
begun in using two liters o normal saline. T ey report
that the patient was shot three times at close range
with an unknown rearm. T e rst wound in the right
upper chest was characterized as sucking on the scene
and has been dressed with an occlusive dressing, taped
on three sides. T ey have already per ormed a needle
decompression. T e second wound is in the le lower
quadrant o the abdomen and is hemostatic. T e nal
wound is located in the right mid-thigh and is presently
hemostatic. Paramedics tell you that the bleeding was
pulsatile prior to the application o a tourniquet.
1. Your rst priority or this patient should be:
A. Establishing a de nitive airway.
B. Per orming a chest X-ray.
C. Removing the tourniquet on the patients right
lower extremity.
D. Placing a le -sided tube thoracostomy.
E. Placing a central venous catheter.
2. Your patient undergoes a rapid sequence intuba-
tion, has a lef -sided tube thoracostomy placed
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with prompt return o air and 1800 mL blood, and
has the remainder o the two liters o crystalloid
in used via EMS. You remove the tourniquet and
immediately appreciate pulsatile bleeding. Distal
right lower extremity pulses are not palpable
prior to the re-application o this device and
with resultant hemostasis. T e patients heart
rate has increased to 120 beats per minute with
a blood pressure o 86/44. With your primary
survey completed, which o the ollowing injuries
necessitates urgent operative intervention?
A. Gunshot wound to the chest only.
B. Gunshot wound to the abdomen only.
C. Right lower extremity injury only.
D. Right lower extremity injury and the chest injury.
E. Right lower extremity injury, abdominal injury,
and chest injury.
3. Regarding penetrating chest trauma, which o the
ollowing is correct?
A. amponade physiology requires accumula-
tion o at least 150cc o blood in the pericardial
space.
B. 85% o injuries can be managed with tube thora-
costomy alone.
C. Great vessel injuries are common in penetrating
chest trauma.
D. Lung injury that requires operative intervention
is more common ollowing blunt injury.
E. Prophylactic antibiotic use reduces the incidence
o post-traumatic empyema in the setting o
retained hemothorax.
 C H AP TER 6 9 P En ETRATi n g TRAu m A m u l Ti P l E g u n s H o T Wo u n d s
4. Regarding this patients penetrating abdominal
wound, which o the ollowing is correct?
A. Injuries to the bowel may be primarily repaired i
less than 75% o the bowels circum erence being
involved.
B. T e most common organ injured is the large
bowel.
C. FAS ( ocused assessment with sonography or
trauma) examination is poor at detecting hollow
viscous injuries.
D. All patients with penetrating abdominal injuries
that violates the posterior ascia must undergo
an exploration but a laparoscopic one may
su ce.
E. T e operation o choice in an unstable patient
having sustained penetrating abdominal injury
is a limited laparotomy with extension only i
injuries are suspected.
ANSWERS
Gunshot wounds all under the broad classi cation o
penetrating trauma and comprise up to 10% o all major
trauma in the United States. T e energy imparted to tis-
sue can be calculated using the kinetic energy equation:
Ke = m(v)2, where m is the mass o the projectile and
v is the change in velocity be ore and a er contact.
Simplistically, it can be in erred that higher caliber re-
arms and those projecting higher velocities will cause
more grievous injury. T is assumes, o course, that the
entirety o the projectiles kinetic energy is imparted
to the tissue. T ose bullets that enter and exit do not
expend all o their kinetic energy on the body. Further-
more, the projectiles behavior in the body is a unction
o its relative density. Lower density projectiles (e.g.,
lead or so-called hollow-point bullets) will tend to
expand, creating a progressively enlarging wound tract
with a comparatively small entrance wound and a large
exit wound. High density and/or high velocity projec-
tiles tend to pass directly through tissue but can cause
signi cant indirect injury via cavitation. Even urther,
high density tissue like bone can dramatically alter the
initial trajectory, de ecting the projectile in nearly any
direction. It is imperative that patients who have sus-
tained gunshot wounds undergo a systematic evalu-
ation with complete anatomic exposure and physical
examination.
1. A. T e primary survey on trauma patients ollows
an algorithmic approach to prevent overlooking
potentially li e-threatening pathology. Patients with
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253
gunshot wounds are no exception. Evaluation and
stabilization o the patients airway to ensure ade-
quate oxygenation and ventilation represents the rst
step in resuscitation. T is sort o vignette is ubiqui-
tous on board examinations and the admonition is to
Keep it Simple, by ollowing the algorithm deline-
ated by Advanced rauma Li e Support. Remember
the acronym ABCDE or the primary survey. T is
involves assessing the patients airway and maintain-
ing in-line cervical spine immobilization, ensur-
ing adequacy o the patients breathing by assessing
both oxygenation (via pulse oximetry) and ventila-
tion (evaluating respiratory rate and e ort), circula-
tion (pulse examination, addressing li e-threatening
bleeding), disability (neurologic examination), and
exposure (strip patient and per orm rapid scan or
injuries). It is important to be mind ul that with a
team approach in a working trauma, much o the
above can be per ormed simultaneously.
For our patient, his unresponsiveness, agonal
breathing, and oxygen desaturation are concerning
and a de nitive airway is indicated. While a chest
X-ray will be per ormed and the le -sided needle
decompression will need to be supplanted by a tube
thoracostomy, these are o subsidiary importance to
securing the patients airway. A central venous cath-
eter is not necessary at this time given the presence o
two large bore peripheral IVs. While it will be impor-
tant to take down the patients tourniquet to per orm
a detailed extremity evaluation, the report o pulsatile
bleeding in the eld is suggestive o vascular injury
and given present hemostasis, this can be de erred
until the initial resuscitation has been per ormed.
2. E. Knowing the indications or operative interven-
tion is essential to caring or patients having sus-
tained traumatic injuries. For penetrating thoracic
trauma, immediate resuscitative thoracotomy (the
so-called Emergency Department T oracotomy)
is indicated or witnessed pulseless electrical activ-
ity (overall survival 4% to 5% or gunshot wounds
vs. 18% to 24% or stab wounds). Urgent thoracot-
omy (within 1 to 4 hours o admission) is indicated
or: initial chest tube output > 1500 mL, evidence o
ongoing bleeding at a rate o 200300 mL/h, massive
air leak, or cardiac tamponade.
For abdominal trauma, indications or laparot-
omy include hemodynamic instability, peritonitis on
examination, or evisceration. Strong consideration
should also be given to exploration or those patients
254 g En ERAl s u Rg ERY EXAm i n ATi o n An d Bo ARd REVi EW
with an abdomen that cannot be evaluated clinically
(e.g., due to altered mental status, distracting injury,
paralytic/sedative administration, etc.).
Hard signs o arterial injury include pulsatile
hemorrhage, expanding/pulsatile hematoma, bruit
or thrill over wound, absent distal pulses, or evidence
to suggest extremity ischemia (pallor, poikilother-
mia, pain, paralysis). So-called so signs include
non-expanding hematoma, peripheral nerve de -
cit, history o pulsatile hemorrhage at the time o
injury, and unexplained hypotension. Any patient
presenting with hard signs o vascular injury should
undergo prompt exploration as the positive predic-
tive value o physical examination or arterial injury
approaches 100%. In the absence o hard signs, an
alternate means o per orming a bedside evalua-
tion is with the injured extremity index (analogous
to an ankle-brachial index, also known as an arterial
pressure index) with a normal value o > 0.9 having
a reported sensitivity/speci city o 95/97% respec-
tively or major vascular injury. A normal physical
examination and injured extremity index virtually
exclude major arterial injury.
3. B. Most thoracic injuries can be managed with tube
thoracostomy; only 10% to 15% o thoracic trauma
requires operative intervention. amponade physi-
ology classically only requires 50 cc o blood in
the pericardial space and is characterized clinically
by Becks riad (jugular venous distention, muf ed
heart sounds, hypotension), occasionally with a nar-
rowed pulse pressure, and the presence o an e usion
on FAS examination.
Patients with tamponade physiology should
receive aggressive volume administration because
they will be dependent on their preload to generate
cardiac output. Decompressive pericardiocentesis
may be per ormed though in the setting o trauma,
but this is o en a temporizing measure. De ni-
tive surgical management in this setting o trauma
involves the creation o a pericardial window.
T e reported incidence o great vessel injury in
penetrating chest trauma is only 4%, as the major-
ity o these patients exsanguinate prior to presenta-
tion. Gunshot wounds to the mediastinum should
raise suspicion and the diagnosis can be con rmed
with C angiography. I present, urgent exploration
is warranted.
Lung injury that requires surgical intervention
is more commonly encountered with penetrating
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trauma. T e majority o these injuries can be man-
aged with pulmonary tractotomy ( or penetrating
non-hilar injuries) or nonanatomic stapled resec-
tions. Inadequately evacuated hemothorax can result
in secondary in ection (post-traumatic empyema)
or brothorax (entrapped lung). Un ortunately,
prophylactic antibiotics do not appear to prevent
the secondary development o in ection in this set-
ting. Chest tubes are o en unsuccess ul in remov-
ing clotted blood and consideration should be given
to operative exploration or patients with retained
hemothorax.
4. C. While a FAS examination is a use ul bedside
adjunct to detect the presence o ree intra-abdominal
or pericardial uid, it is operator dependent and has
a poor sensitivity with respect to hollow viscous, ret-
roperitoneal, and diaphragmatic injuries. A negative
FAS examination does not rule out intra-peritoneal
injury. T ere is evidence to suggest that hemody-
namically stable patients with abdominal gunshot
wounds and no evidence o peritonitis on exam may
undergo evaluation via computerized tomography o
the abdomen to determine whether urther operative
intervention is required. Even i the posterior ascia
is violated, elective non-operative management with
observation and serial examinations is a sa e alterna-
tive to re ex operative exploration in a major trauma
center with in-hospital surgical support.
In general, primary repairs can be done on both
small and large bowel i 50% or less o the circum-
erence is damaged. T e most commonly injured
abdominal organ with penetrating trauma is the
small bowel. For unstable patients with penetrating
abdominal injuries, a ull laparotomy incision should
be made so that all o the injuries can be identi ed
quickly.
BIBLIOGRAPHY
American College o Surgeons Committee on rauma.
Advanced Trauma Life Support (ATLS) Student Course Man-
ual. 9th ed. Chicago: American College o Surgeons; 2012.
Boulanger BR, Kearney PA, suei B, Ochoa JB. T e routine
use o sonography in penetrating torso injury is bene cial.
J Trauma. 2001;51(2):320.
Champion HR, Copes WS, Sacco WJ, Lawnick MM, Keast
SL, Bain LW Jr, et al. T e major trauma outcome study:
Establishing national norms or trauma care. J Trauma.
1990;30(11):1356.
Cohn SM. Pulmonary contusion: Review o the clinical entity.
J Trauma. 1997;42(5):9739.
 C H AP TER 6 9 P En ETRATi n g TRAu m A m u l Ti P l E g u n s H o T Wo u n d s
Como JJ, Bokhari F, Chiu WC, Duane M, Holevar MR,
andoh MA, et al. Practice management guidelines
or selective nonoperative management o penetrating
abdominal trauma. J Trauma. 2010;68(3):721.
Demetriades D. Penetrating injuries to the thoracic great ves-
sels. J Card Surg. 1997;12(2):1739.
Demetriades D, Hadjizacharia P, Constantinou C, Brown C,
Inaba K, Rhee P, et al. Selective nonoperative management
o penetrating abdominal solid organ injuries. Ann Surg.
2006;244(4):6208.
Demetriades D,Velmahos GC. Penetrating injuries o the chest:
indications or operation. Scand J Surg. 2002;91(1):415.
Frykberg ER, Dennis JW, Bishop K, Laneve L, Alexander RH.
T e reliability o physical examination in the evaluation o
penetrating extremity trauma or vascular injury: Results
at one year. J Trauma. 1991;31(4):502.
Hines MH, Meredith JW. Special problems o thoracic trauma.
In: Ritchie WP, Steele G Jr., Dean RH, eds. General surgery.
Philadelphia, PA: JB Lippincott; 1995:85972.
Hoth JJ, Burch P , Bullock K, et al. Pathogenesis o post-
traumatic empyema: T e impact o pneumonia on pleural
space in ections. Surg Infect (Larchmt). 2003;4(1):2935.
Isenhour JL, Marx J. Advances in abdominal trauma. Emer-
gency Clinics of North America. 2007;25:713.
Johansen K, Lynch K, Paun M, Copass M. Non-invasive vas-
cular tests reliably exclude occult arterial trauma in injured
extremities. J Trauma. 1991;1(4):5159.
Karmy-Jones R, Jurkovich GJ. Blunt chest trauma. Curr Probl
Surg. 2004;41:211380.
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255
Karmy-Jones R, Jurkovich GJ, Shatz DV, et al. Management o
traumatic lung injury: A western trauma association mul-
ticenter review. J Trauma. 2001;51(6):104953.
Maxwell RA, Campbell DJ, Fabian C, et al. Use o presump-
tive antibiotics ollowing tube thoracostomy or trau-
matic hemopneumothorax in the prevention o empyema
and pneumonia: A multi-center trial. J Trauma. 2004;
57(4):7428.
Meredith JW, Hoth JJ. T oracic trauma: When and how to
intervene. Surg Clin North Am. 2007;87(1):95118.
Natarajan B, Gupta P , Cemaj S, Sorensen M, Hatzoudis
GI, Forse RA. FAS scan: Is it worth doing in hemo-
dynamically stable blunt trauma patients? Surgery.
2010;148(4):695.
Pryor JP, Reilly PM, Dabrowski GP, Grossman MD, Schwab
CW. Nonoperative management o abdominal gunshot
wounds. Ann Emerg Med. 2004;43(3):344.
Velmahos GC, Constantinou C, illou A, Brown CV, Salim
A, Demetriades D. Abdominal computed tomographic
scan or patients with gunshot wounds to the abdo-
men selected or non-operative management. J Trauma.
2005;59(5):1155.
Velmanos GC, Demetriades D, outouzas KG, et al. Selective
nonoperative management in 1856 patients with abdomi-
nal gunshot wounds: Should routine laparotomy still be
the standard o care? Ann Surg. 2001;234(3):395.
Wall MJ Jr, Hirschberg A, Mattox KL. Pulmonary tractotomy
with selective vascular ligation or penetrating injuries to
the lung. Am J Surg. 1994;168(6):6659.
 70
Cervical Spine Clearance

Matthew R. Fusco, Ajith J. T omas, and Christopher S. Ogilvy

A 60-year-old male restrained driver is involved in a
high-speed head-on motor vehicle collision. He is heav-
ily intoxicated and uncooperative, there ore he is intu-
bated at the scene and brought to the nearest Level I
trauma center. Upon arrival he is able to shrug his
shoulders to questions. Initial vital signs indicate a pulse
o 48 bpm and a blood pressure o 78/39 mm Hg. His
respiratory status appears stable on the current ventila-
tor settings and initial primary trauma evaluation ails
to reveal any major external signs o injury.
Subsequent secondary trauma survey reveals the
patient is able to shrug his shoulders but demonstrates
no motor or sensory unction below his deltoids. Ques-
tionable rectal tone is present. A cervical collar is in
place, but the patient demonstrates tenderness to palpa-
tion in the midline o the cervical spine.
1. What is the most likely cause of this patients
hypotension?
A. Splenic rupture
B. Acute blood loss
C. Flail chest
D. Spinal shock
E. Beta-blockade
2. Which of the following is not a component
evaluated by the NEXUS criteria for clearing a
patients cervical spine from injury such that the
cervical collar can be removed?
A. Pain with passive motion o the patients neck
B. History o Ambien use
C. Any other injury
D. Altered mental status
E. High velocity mechanism o injury
3. Which of the following therapeutic measures is
considered a current standard treatment option
for this patients spinal shock?
A. Limited boluses o normal saline or LR to pre-
vent spinal cord edema
B. Bed rest
C. Selective vasopressor treatment to keep MAPs
> 85
D. Administration o methylprednisolone bolus
at 30 mg/kg ollowed by continuous in usion at
5.4 mg/kg/hr or 23 hours
4. Imaging reveals a fracture dislocation of the mid
cervical spine with a resultant spinal cord injury.
Computed tomographic angiography (C A) reveals
a traumatic vertebral artery dissection. Which
of the following is associated with a markedly
increased chance of cervical vascular injury and
thus requires an evaluation with C A?
A. Neurological examination out o proportion with
computerized tomography (C ) head ndings
B. Seat belt sign
C. C5 spinous process racture
D. Glascow coma scale < 10
E. Le Fort I racture
ANSWERS
1. D. Spinal cord injury ollowing a traumatic cervical
spine injury typically results rom blunt compres-
sion injury to the cord itsel . ypically the central grey
matter is a ected rst while the peripherally located
white matter ber tracts may be relatively spared. I

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the spinal cord injury is severe enough, neurogenic or
spinal shock may occur. T e most basic de nition o
this is inadequate tissue per usion due to paralysis o
vasomotor input, most commonly due to loss o sym-
pathetic tone and signi cant disruption o the vaso-
dilator and vasoconstrictor balance. It is commonly
characterized by bradycardia, hypotension, decreased
peripheral vascular resistance, and decreased car-
diac output. Common physical examination ndings
demonstrate accid paralysis o the extremities with
no sensory unction, lack o rectal tone, lack o oley
catheter sensation, and priapism in males. I the spi-
nal cord injury occurs at C5 or above then respiratory
depression may occur. As this patient demonstrates
some deltoid unction, this indicates a lower cervical
cord injury. Presence o a shoulder shrug should not
ool the examiner. T is motor unction is provided by
the 11th cranial nerve. T e most common classi ca-
tion o spinal cord injuries occurs via the ASIA system:
A = Complete No motor or s e ns ory function is pre s e rve d in
the s a cra l s e gme nts S 4S 5
B = Incomplete S e ns ory but no motor function is pre s e rve d
be low the ne urologica l leve l a nd include s
the s a cra l s e gme nts S 4S 5
C = Incomplete Motor function is pre s e rve d be low the
ne urologica l leve l, a nd more tha n ha lf of
key mus cle s be low the ne urologica l leve l
have a mus cle gra de le s s tha n 3
D = Incomplete Motor function is pre s e rve d be low the
ne urologica l leve l, a nd a t le a s t ha lf of key
mus cle s be low the ne urologica l leve l have
a mus cle gra de of 3 or more
E = Normal Motor a nd s e ns ory function a re norma l
2. E. Any patient suspected o a cervical spine injury
and there ore a potentially unstable cervical spine
should be placed in cervical immobilization with a
rigid collar. Maintenance o in-line cervical align-
ment during intubation as well as log-roll precautions
must be upheld during trans ers. Per the NEXUS cri-
teria, a patient can be cleared with a 99.8% negative
predictive value or cervical spine injury i the ol-
lowing criteria are met:
Meets all low-risk criteria?
1. No pos te rior midline ce rvica l-s pine te nde rne s s
2. No evide nce of intoxica tion
3. A norma l leve l of a le rtne s s
4. No foca l ne urologic de ficit
5. No pa inful dis tra cting injurie s
YES NO
No Radiography Radiography
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C H AP TER 7 0 C ERv i C Al S P i n E C l EARAn C E 257
3. C. Current treatment protocols or spinal shock
involve the mainstays o aggressive uid resuscita-
tion and vasopressors. Vasopressor choice is lef to
the discretion o the treating physician based on the
patients co-morbid actors. A goal MAP o > 85 sus-
tained or 7 days has demonstrated some promise or
improving a patients outcome. Usage o high dose
steroids in acute spinal cord injury is a controversial
topic and has been or quite some time. Various large
trials (NASCIS I, II, III) have demonstrated mild
bene ts with the administration o methylpredniso-
lone bolus o 30 mg/kg ollowed by 23 hours o con-
tinuous in usion at 5.4 mg/kg/hour. However, these
studies have also demonstrated signi cant deleteri-
ous side e ects with high dose steroids leading to the
Congress o Neurosurgeons to declare that high dose
steroids risks outweigh their bene ts, and are thus
not recommended.
4. A. Blunt carotid or vertebral artery injuries can be a
potentially lethal injury i missed upon initial trauma
evaluation. Level II evidence exists neck C A screen-
ing in trauma patients with an exam out o proportion
to their cranial imaging (i.e., a comatose patient with
minimal traumatic intracranial damage). Level III
evidence exists or such screening in trauma patients
with GCS 8 or below, petrous bone ractures, di use
axonal injury, C13 ractures, any cervical spine rac-
ture with subluxation, cervical spine racture through
the oramen transervsarium, or Le Fort II/III injuries.
Surprisingly, despite its widely believed association
with cervical vascular injuries, presence o an isolated
seat belt sign with no other above listed injuries is
only associated with a 1% yield or blunt cervical
vascular injuries. reatment o such blunt injuries
attempt to prevent intracranial ischemic injuries.
Previously aggressive treatment with open surgical
or endovascular repair, of en in the orm o stent-
ing or coiling, provided the mainstay o treatment.
However, current emerging evidence suggests these
lesions, i diagnosed prior to evidence o ischemia,
can be quite benign i treated with antithrombotic
medications. Currently, either anticoagulation via
heparin/Coumadin or anti-platelet medications via
aspirin 325 mg daily are widely used.
BIBLIOGRAPHY
Aarabi B, Hadley MN, Dhall SS, Gelb DE, Hurlbert RJ,
Rozzelle CJ, et al. Management o acute traumatic central
cord syndrome (A CCS). Neurosurgery. 2013;72(2):195204.
258 G En ERAl S U RG ERY EXAM i n ATi O n An D BO ARD REv i EW
Dumont RJ, Okonkwo DO, Verma S, Hurlbert RJ, Boulos P ,
Ellegala DB, et al. Acute spinal cord injury, part I: patho-
physiologic mechanisms. Clin. Neuropharmacol. 2001;24:
25464.
Harrigan MR, Hadley MN, Dhall SS, Walters BC, Aarabi B,
Gelb DE, et al. Management o vertebral artery injuries
ollowing non-penetrating cervical trauma. Neurosurgery.
2013;72(2),23443.
http://surgerybook.net/
Hurlbert RJ, Hadley MN, Walters BC, Aarabi B, Dhall SS, Gelb
DE, et al. Pharmacological therapy or acute spinal cord
injury. Neurosurgery. 2013;72(2);93105.
Michale ZA, Maher CG, Verhagen AP, Rebbeck , Lin C-WC.
Accuracy o the Canadian C-spine rule and NEXUS to
screen or clinically important cervical spine injury in
patients ollowing blunt trauma: A systematic review. CMAJ
Can. Med. Assoc. J. J. Assoc. Medicale Can. 2012;184:E86776.
 71
Management o Elevated
Intracranial Pressure
Matthew R. Fusco, Ajith J. T omas, and Christopher S. Ogilvy

A 32-year-old male, unrestrained driver, is involved in 3. Which o the ollowing should be implemented in
a high-speed motor vehicle collision. A er a prolonged this patient ollowing external ventricular drain
extraction, the patient is ound to be somnolent and is placement and admission to the ICU?
intubated on the scene. A er arrival in the trauma center, A. Elevation o the head o bed to up to 10 degrees
a complete evaluation reveals a non-displaced linear so measurement o the intracranial pressure
skull racture and multiple areas o intracranial contu- (ICP) remains calibrated
sions with di use edema but no large mass lesions. No B. Maintain hemoglobin levels > 10 g/dL
other systemic injuries are discovered. His neurologic C. Maintenance o a cerebral per usion pressure o
exam demonstrates small but reactive pupils, presence 60 or above
o corneal, gag, and cough re exes, lack o eye opening D. Allow hypercapnia
to voice or pain ul stimulation, brisk withdrawal o both E. Administration o high levels o positive end-
legs and his right arm to pain ul stimulation as well as expiratory pressure (PEEP) to aid in oxygena-
localization o his le arm to pain ul stimulation. tion
1. What is the patients Glasgow Coma Scale (GCS)?
A. 5 4. On post-admission day 2, the patients intracranial
B. 6 pressures rise to the low 30s. Which o the ollowing
C. 7 maneuvers can be used to reduce his intracranial
D. 8 pressure?
E. 9 A. Increased sedation with propo ol only because
other sedatives can increase cerebral metabolic
2. Which o the ollowing are indications or the use demand
o intracranial pressure monitoring in traumatic B. 3% hypertonic saline
brain injury? C. Permissive hypotension
A. Intracranial injury demonstrated on computer- D. ransient periods o hypoventilation
ized tomography (C ) scan and GCS o 8 or below. E. Administration o methylprednisolone
B. Lack o intracranial injury on C scan, but age
> 40, SBP < 90, and motor posturing on exam.
ANSWERS
C. Minor neurologic injury but lack o neurologic
examination due to need or systemic paralytics 1. C. T e Glasgow Coma Scale (GCS) is the most basic
in treatment o other injuries. method o quickly communicating a patients neuro-
D. All o the above. logic examination. It is comprised o three compo-
E. None o the above. nents:

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260 G EN ERAL S U RG ERY EXAM IN ATI O N AN D BO ARD REVIEW
Eye Opening (E) Verbal Response (V)
4= opens spontaneously 5= normal conversation
3= opens to voice 4= disoriented conversation
2= opens to pain 3= words, incoherent
1= none 2= incomprehensible sounds
1= none
T us, a non-responsive comatose patient has a
GCS o 3 while an awake, oriented patient would
demonstrate a GCS o 15. Intubated patients auto-
matically receive just 1 point or verbal response. I a
patients motor exam is asymmetric, the best response
is used or grading. T us this patients exam is E1, V1,
M5 or a total GCS o 7. For intubated patients, many
providers use the convention o adding a ollow-
ing the GCS score, so this patient would be described
as a GCS 7 .
2. D. Insertion o an intracranial pressure monitor can
be used to evaluate and treat elevated ICP or as a sur-
rogate or a neurologic examination in those who
require sedation or chemical paralysis or other inju-
ries (such as a trauma patient with an open abdomen
on paralytics). T e most common indication or an
ICP monitor is a patient with a traumatic intracra-
nial injury on imaging and a GCS o 8 or less. T ese
patients will have an elevated ICP 60% o the time.
Patients with a normal head C scan will only dem-
onstrate elevated ICP 13% o the time. T is occurs
most commonly in patients over 40 years o age who
demonstrate posturing on examination and hypo-
tension.
3. C. T e Monro-Kellie doctrine states that the skull is
a xed compartment with 3 basic components: brain
(80%), cerebrospinal uid (10%), and blood (10%).
An increase in any one o these components requires
an equal decrease in one or both o the other two to
prevent an increase in intracranial pressure. ypical
cerebral blood ow compromises 1520% o the car-
diac output; a decrease in this may result in unmet
cerebral metabolic demands. T e primary goal o
treatment o severe brain injury is to maintain ade-
quate cerebral blood ow and oxygen delivery, but it
is dif cult to readily measure these parameters. How-
ever, cerebral blood ow can be roughly estimated by
cerebral per usion pressure (CPP = MAP ICP),
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Motor Response (M)
6= normal
5= localizes pain
4= withdraws rom pain
3= decorticate posturing
2= decerebrate posturing
1= none
and is commonly used to guide therapy. In uninjured
patients, the brain will maintain cerebral per usion
via autoregulation over estimated CPP ranges o 50
to 150.
However, patients with severe brain injury will
commonly exhibit loss o autoregulation, which
means that their cerebral blood ow will be directly
dependent on an adequate mean arterial pressure
(MAP) and a normal intracranial pressure (ICP).
T is is why there is so much attention paid to main-
taining a normal to slightly elevated blood pressure
and aggressive measures to avoid ICP elevations in
patients with severe brain injury.
All attempts at treating elevated intracranial pres-
sure keep this Monro-Kellie hypothesis and its rela-
tionship with cerebral per usion pressure in mind.
T e rst steps toward the treatment o a patient with
elevated intracranial pressure begin with many sim-
ple bedside maneuvers. Initial steps should include
elevation o the head o bed to aid cerebral venous
out ow, seizure prophylaxis, maintenance o hemo-
globin o at least 7 g/dL or above, avoidance o
elevated intra-adominal pressure, and adequate pul-
monary support. Pulmonary support should ocus
o avoidance o hypoxia, hypercapnia, and exces-
sive PEEP. Elevated levels o PaCO2 lead to intrac-
ranial vasodilation and cerebral blood volume, thus
elevated ICP. Excessive PEEP may lead to increased
intra-thoracic pressure and thus impaired cerebral
venous out ow.
4. B. I elevated ICP occurs, more aggressive methods
o treatment include increased sedation (via propo-
ol or barbituates to decreased cerebral metabolic
demands), paralytics, mannitol or both rheologic
and osmotic e ects, and hypertonic saline. Steroids
should be avoided in intracranial trauma. Despite
the usage o dexamethasone with other causes
o cerebral edema, steroids are associated with
elevated mortality in trauma patients with severe
 C H AP TER 7 1 MAN AG EM EN T O f ELEVATED I N TRAC RAN I AL P RES S U RE
brain injury due to the myriad o side ef ects. Hypo-
tension should be avoided to help maintain the CPP.
BIBLIOGRAPHY
Brain rauma Foundation, American Association o Neuro-
logical Surgeons, Congress o Neurological Surgeons, Joint
Section on Neurotrauma and Critical Care, AANS/CNS,
Bratton SL, Chestnut RM, et al.: Guidelines or the man-
agement o severe traumatic brain injury. I. Blood pressure
and oxygenation. J. Neurotrauma. 2007;24(1):S713. doi:
10.1089/neu.2007.9995
Brain rauma Foundation, American Association o Neu-
rological Surgeons, Congress o Neurological Surgeons,
Joint Section on Neurotrauma and Critical Care, AANS/
CNS, Bratton SL, Chestnut RM, et al.: Guidelines or the
management o severe traumatic brain injury. VII. Intra-
cranial pressure monitoring technology. J. Neurotrauma.
2007;24(1):S4554. doi: 10.1089/neu.2007.9989
http://surgerybook.net/
2 61
Brain rauma Foundation, American Association o Neu-
rological Surgeons, Congress o Neurological Surgeons,
Joint Section on Neurotrauma and Critical Care, AANS/
CNS, Bratton SL, Chestnut RM, et al.: Guidelines or the
management o severe traumatic brain injury. XIII. Anti-
seizure prophylaxis. J. Neurotrauma. 2007;24(1):S8386.
doi: 10.1089/neu.2007.9983
Brain rauma Foundation, American Association o Neuro-
logical Surgeons, Congress o Neurological Surgeons, Joint
Section on Neurotrauma and Critical Care, AANS/CNS,
Bratton SL, Chestnut RM, et al.: Guidelines or the man-
agement o severe traumatic brain injury. XIV. Hyperven-
tilation. J. Neurotrauma. 2007;24(1):S8790. doi: 10.1089/
neu.2007.9982
Edwards P, Arango M, Balica L, Cottingham R, El-Sayed H,
Farrell B, et al. Final results o MRC CRASH, a randomised
placebo-controlled trial o intravenous corticosteroid in
adults with head injury-outcomes at 6 months. Lancet.
2005;365:19579. doi: 10.1016/S0140-6736(05)66552-X
 72
Ortho- raumaPelvic Fracture
William J. Jordan
A 27-year-old emale presents to the emergency depart-
ment a er a motorcycle crash. She was hemodynami-
cally unstable on arrival and is currently receiving 2L o
crystalloid via large bore peripheral IVs. Glasgow Coma
Scale (GCS) is 12. She is breathing spontaneously and
has no obvious extremity trauma. Initial radiographs
demonstrate normal cervical alignment without rac-
ture, right side ribs 4 through 8 ractured, a small right
side pulmonary contusion, no ree air under the dia-
phragm, and a pelvis lm that shows widening o the
pubic symphasis by 4 cm along with diastasis o the le
sacroiliac joint. Abdominal ultrasound is negative or
ree uid. T e patient is currently on her menses.
1. With regards to the pelvic injury, the patients
hemodynamic instability is most likely related to:
A. Disruption o the anastomis o the external
iliac/deep epigastric and obturator vessels (the
Corona Mortis)
B. Arterial injury o the superior gluteal artery and
vein at the level o the greater sciatic notch
C. Post-traumatic closed so tissue degloving
injury in which the skin and subcutaneous tissue
separate rom the ascia super cial to the under-
lying musculature (Morel-Lavallee lesion)
D. Disruption o the anterior sacral venous plexus.
E. Rupture o the pelvic oor structures (sacrospi-
nous and sacrotuberrous ligaments) with vaginal
laceration by the anterior pubic symphasis rag-
ments
2. What percentage o vascular injuries rom high-
energy pelvic trauma are arterial in nature?
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A. < 5%
B. 10% to 15%
C. 50%
D. 60% to 75%
E. > 85%
3. Regarding the hemodynamic instability o pelvic
ractures, what is the racture pattern associated
with the highest severity o hemorrhage?
A. Anteroposterior compression (APC III) racture
patterns
B. Lateral compression (LC III) racture patterns
C. Vertical sheer (VS) racture patterns
D. Combined APC/VS patterns
E. Open pelvic ractures
4. Regarding the mortality o displaced pelvic
ractures, the highest mortality rates are seen in:
A. Anteroposterior compression (APC III) racture
patterns
B. Lateral compression (LC III) racture patterns
C. Vertical sheer (VS) racture patterns
D. Combined APC/VS patterns
E. Open pelvic ractures
5. Identi cation and management o open pelvic
ractures depends on a high index o suspicion by
the initial treating provider. Although this patient
was on her menses and blood was to be expected
on examination, a speculum examination o the
vaginal mucosa demonstrates a 2 cm laceration
on the lef wall o the vagina and a proctoscopic
exam showed a rectal laceration. To decrease the
 C H AP TER 7 2 O RTH O - TRAu m A P El v i C F RAC Tu RE
risk or post-injury in ection and sepsis, which o
the ollowing should occur early in the treatment
o this injury?
A. Urgent gynecological consultation with primary
closure o vaginal laceration
B. Exploratory laparotomy or laparoscopy with
repair o rectal laceration and diverting colos-
tomy
C. Exploratory laparotomy with repair o rectal lac-
eration without diversion
D. Urgent urological consultation with repair o
bladder and urethral injuries
E. Immediate placement o a suprapubic catheter
ANSWERS
1. D. Hemodynamic instability a er blunt trauma is
due to ongoing hemorrhage until proven otherwise,
with the common locations being the chest, abdo-
men, pelvis, or extremity/external bleeding. T e
normal chest X-ray and abdominal ultrasound in
conjunction with the abnormal pelvis X-ray make
the pelvis the most likely source o bleeding in this
patient. Although arterial injuries in association with
major pelvic trauma can occur, the majority o bleed-
ing occurs at the venous plexus located on the ante-
rior aspect o the sacrum and sacroiliac joints. T is
historically has responded best to pelvic packing or
racture reduction, rather than immediate angiog-
raphy. Injuries to the superior gluteal arteries pos-
teriorly and the Corona Mortis anteriorly have been
reported and can be devastating, but they are ar out-
numbered by the venous lacerations o the presacral
venous plexus. Morel-Lavallee lesions are common
a er blunt orce trauma, but do not typically lead to
hemodynamic instability seen rom the deep pelvic
venous lacerations.
2. B. T e current management o pelvic racture
patients who are hemodynamically unstable consists
o aggressive resuscitation, mechanical stabilization,
and angioembolization. Despite this multidiscipli-
nary approach, mortality rates o these high-risk
patients can exceed 40%. Initial maneuvers to reduce
the pelvic racture and decrease the pelvic volume
include placement o a pelvic binder, wrapping the
pelvis with a sheet, or application o an external xa-
tion device. Preperitoneal pelvic packing (PPP) via
laparotomy can directly address the venous bleeding
that compromises 85% o pelvic racture hemorrhage
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263
and does not respond to the initial maneuvers listed
above. T e remaining 15% o vascular injuries are
arterial and may best be addressed via angiography
in the event o continued hemodynamic instability
ollowing pelvic packing.
3. A. In an antero-posterior compression racture
(APC), the racture propagates rom anterior to poste-
rior. T is widens the symphasis pubis and depending
on the level o orce, can widen the anterior sacroiliac
joint or disrupt it entirely. In an APC III injury, the
pelvic oor ligaments (sacrospinous and sacrotuber-
ous) are disrupted and can leading to instability and
increased volume in the pelvic cavity. Disruption and
displacement o the sacroiliac joint has the potential
to lead to massive hemorrhage rom the anterior
sacral venous plexus that is closely approximated to
the joint. Major hemorrhage in patients with pelvic
ractures can reliably be predicted based on a pulse
greater than 130, a hematocrit o 30 or less, and wide
diastasis o the pubic symphasis.
Although pelvic binders are now routinely applied
or suspected or proven pelvic ractures, they may
have no bene t or may even cause additional harm in
select types o ractures. T e AP pelvic radiograph will
identi y injuries that may bene t rom provisional sta-
bilization with external compression with a sheet or
pelvic binder. In general, LC injuries will not respond
to binder placement, whereas APC and VS injuries
will. Compression o an LC injury is potentially dam-
aging as it may induce additional lateral compression
and racture dislocation or bleeding. Occasionally, an
LC injury in an elderly patient may have a hemor-
rhage associated with vascular or visceral disruption;
these patients will not bene t rom wrapping or bind-
ing, but may be candidates or angiography.
4. E. Open pelvic ractures are potentially lethal inju-
ries with a reported mortality rate o 30% to 50%.
Open ractures o the pelvis by de nition communi-
cate with the rectum, the vagina, or the outside envi-
ronment by disruption o the skin. T ey are o en
associated with disruption o the pelvic oor, lead-
ing to loss o tamponade and persistent bleeding. An
additional concern is pelvic in ection and sepsis due
to the open communication with the rectum, vagina,
or skin. Clinical suspicion o an open racture and
any rectal or vaginal bleeding mandates a thorough
examination o the pelvis, perineum, rectum/anal
complex, and vagina in emales.
264 G EN ERAl S u RG ERY EXAm i N ATi O N AN D BO ARD REv i EW
In addition to visual inspection and digital exami-
nation, ull evaluation should include rigid proc-
toscopy or exible sigmoidoscopy, and speculum
examination in emales. Management o major open
pelvic ractures includes administration o intrave-
nous antibiotics, washout and debridement o open
wounds, and consideration or a possible diverting
colostomy to prevent ecal contamination o the
open racture.
5. B. Early diagnosis o an open pelvic racture is essen-
tial and a thorough examination must be done so that
no such injuries are missed. While it is not dif cult to
diagnose an open racture when massive wounds o
the skin and perineum are present, a small vaginal or
rectal tear that communicates with and contaminates
the racture may be missed unless it is sought speci -
cally. Rectal injuries must be sought, particularly in
patients with a sacral racture, because the ragments
o bone requently traverse the rectal wall.
Classically, an open pelvic racture prompts rec-
ommendations or colostomy to prevent so -tissue
sepsis in an expanded perineum. It has recently
been suggested that ecal diversion in an open pel-
vic ractures can be applied selectively, according to
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the actual location, nature, and size o the cutaneous
wound. For open ractures with an associated rectal
injury, immediate diverting colostomy and repair o
the rectal laceration (i possible) are indicated. Ante-
rior wounds o the groin, anterior thigh, iliac crest, or
pubis do not require diversion.
BIBLIOGRAPHY
Blackmore CC, Cummings P, Jurkovich GJ, Linnau KF, Ho -
er EK, Rivara FP. Predicting major hemorrhage in patients
with pelvic racture. J Trauma. August 2006;61(2):34652.
Cothren CC, Osborn PM, Moore EE, Morgan SJ, Johnson JL,
Smith WR. Perperitoneal pelvic packing or hemody-
namically unstable pelvic ractures: a paradigm shi .
J Trauma. 2007;62(4):83442.
Fallinger MS, McGanity PL. Unstable ractures o the pelvic
ring. J Bone Joint Surg Am. June 1992;74(5):78191.
Lang ord JR, Burgess AR, Liporace FA, Haldukewych GJ.
Pelvic Fractures: Part 1: Evaluation, classi cation, and resus-
citation. J Am Acad Orthop Surg. August 2013;21(8):448
57.
Mohanty K, Musso D, Powell JN, Kortbeek JB, Kirkpatrick
AW. Emergent management o pelvic ring injuries: An
update. Can J Surg. February 2005;48(1):4956.
al DK, et al. Retroperitoneal pelvic packing in the manage-
ment o hemodynamically unstable pelvis ractures: A
level 1 trauma center experience. J Trauma. October 2011;
71(4):E7986.
 73
Head Injuries

Ahmed B. Bayoumi, Fares Nigim, and Ekkehard M. Kasper

CASE 1
A 44-year-old emale patient presented with a history o
pro use bleeding rom a scalp wound. She was brought
to the emergency room by an attendant. She had direct
trauma caused by alling and hitting her head on a large
rock while hiking. She denied any loss o conscious-
ness or seizures. T e bleeding was controlled by a gauze
dressing and compression bandage at the site o the
injury. She was vitally stable with a Glasgow Coma Scale
(GCS) o 15/15. On neurological examination, she had
no motor de cit except or right sided lower motor neu-
ron (LMN) acial palsy. A large, parietal lacerated scalp
wound was visible 3 cm away rom the midline on the
le , measuring about 2 cm in length. A computerized
tomography (C ) o her head was done a er she com-
plained o having an abnormal salty taste in her mouth.
On leaning orward she had drops o clear uid coming
rom her nose.
T e head C is shown in Figure 73-1. Figure 73-1

1. Which o the ollowing is an indication or surgical
intervention?
A. Depression that does not exceed the calvarial
thickness
B. Associated intracranial hematoma without a
mass e ect
C. An isolated clean racture overlying a dural
venous sinus in an asymptomatic patient
D. Dural injury with persistent cerebrospinal uid
(CSF) leak
E. Because this is an open skull racture then opera-
tive intervention is mandated.
2. Regarding the management o this type o racture,
which o the ollowing is true?
A. Early surgical intervention may decrease the risk
traumatic brain injury.
B. Antibiotics are recommended in almost all cases.
C. Even i there is evidence o a wound in ection,
primary bone repair will have a avorable out-
come.
D. Elevation o depressed racture usually lowers
the risk o post-traumatic seizures.
E. Severe cosmetic de ormity is an indication or
urgent surgery.

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266 G EN ERAL S U RG ERY EXAM I N ATI O N AN D BO ARD REVI EW
3. Four hours later, another patient with the same type
o head injury came to the ER but he deteriorated
immediately af er admission. His head C
(Figure 73-2) showed the ollowing image:
Figure 73-2
T e main cause o deterioration o this patient is:
A. ension pneumocephalus
B. Acute obstructive hydrocephalus
C. Hydrocephalus ex vacuo
D. Subdural hygroma
E. Subdural hematoma
4. Regarding the CSF rhinorrhea/otorrhea, which o
the ollowing is true?
A. CSF has a lower concentration o glucose than
does mucus.
B. Magnetic resonance imaging (MRI) is the most
sensitive procedure to localize the site o CSF
stula.
C. Meningococci are the most common pathogen
that may cause meningitis in this condition.
D. Post-traumatic CSF rhinorrhea is more likely to
persist compared to spontaneous CSF rhinorrhea.
E. Post-traumatic CSF otorrhea is usually sel -
limited.
CASE 2
A 30-year-old male A rican patient presents to the emer-
gency department with altered level o consciousness
ollowing direct trauma to the head by a heavy object
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about 3 hours prior to arrival. He was brought in by his
riend, who said that he had transient loss o consciousness
or about one minute a er which he woke up complain-
ing o headache and blurry vision. He vomited once be ore
becoming somnolent and again about 30 minutes later.
On general examination, his vital signs were as ol-
lows: BP = 140/85 mm Hg, RR = 18 cycle/min, Pulse =
68 beat/min, and GCS = 10/15. Bruises were seen
over the right temple. On neurological examination,
the patient had a le hemiparesis with round, equal,
and reactive pupils. T e patient was mildly agitated
with good localization o pain ul stimuli. Deep tendon
re exes (D Rs) were mildly exaggerated with a positive
Babinskis sign on the le side.
A thorough examination was done to exclude associ-
ated injuries o the spine, chest, and abdomen. A rigid
cervical collar had been placed in the eld by EMS. Brain
imaging via C scan revealed a large, right parieto-
temporal epidural hematoma. Cervical spine images
were unremarkable. Emergent surgical intervention was
per ormed with postoperative ICU admission or strict
monitoring o vital signs and neurological status.
1. Regarding the etiology o cranial epidural
hematoma (EDH), which o the ollowing is correct?
A. T e most common source o bleeding in this case
o EDH is an injured anterior division o middle
meningeal artery running beneath the pterion.
B. EDH cannot be caused by injury o dural venous
sinuses.
C. An underlying racture is not commonly ound
in cases o post-traumatic EDH.
D. T e bridging cortical veins are usually torn in
cases o EDH with associated extensive brain
lacerations.
E. T e source o bleeding in traumatic EDH and
acute subdural hematoma (aSDH) is usually
arterial.
2. Regarding the clinical presentation o patients with
cranial EDH, which o the ollowing is correct?
A. EDH is more common in older patients with a
1:3 male to emale ratio.
B. A lucid interval is reported in more than 80% o
traumatic EDH.
C. All cases o EDH present with altered level o
consciousness.
D. Anisocoria occurs in cases o rapidly expanding
temporal EDH secondary to central transtento-
rial herniation.
 C H AP TER 7 3 H EAD I N j U RI ES 267

E. Motor de cit (e.g., hemiparesis) may occur ipsi-
lateral to the side o hematoma due to compres-
sion against Kernohans notch.
F. Symptoms o increased intracranial pressure
(ICP; e.g., vomiting) are o en more pro ound in
supratentorial EDH compared to the posterior
ossa EDH.
C. Bradycardia and hypotension are both part o
Cushings triad in markedly elevated ICP.
D. Preoperative decerebration does not predict
morbidity in closed head injuries.
E. Presence o a skull racture is a risk actor or the
development o a delayed EDH.

3. Regarding the diagnosis o cranial EDH, which o CASE 3

the ollowing is correct?
A. C scan o the head is the standard imaging
modality that reveals cranial EDH without the
need or IV contrast.
B. EDH is usually crescentic in shape on C imag-
ing, while aSDH is more lenticular with biconvex
borders.
C. EDH is usually di use beneath the cranial bone
and appears limited by the alx.
D. T e resh, undiluted blood o an EDH appears as
a hypodense mass on head C scan.
E. A positive swirl sign on a C scan o the head
indicates a long-standing EDH, which can be
treated conservatively.
A 21-year-old male Caucasian patient was brought into
the emergency room by his girl riend. She described
an episode o a le acio-brachial seizure about 1 hour
a er he had a motorbike accident. T e patient had
shown a transient loss o consciousness at the scene.
Upon regaining consciousness he complained only o
a headache be ore he developed the seizure. On general
examination, vital signs were ound to be within nor-
mal limits. On neurological examination, he was ound
to still be in post-ictal status but without any motor
de cit. Intravenous Fosphenytoin was administered
and a non-contrast head C was requested to exclude
intracranial bleeding. T e axial head C can be seen in
Figure 73-3.

4. Regarding the management o cranial EDH, which

o the ollowing is correct?
A. Lumbar puncture is recommended to allevi-
ate elevated ICP symptoms in cases o temporal
EDH.
B. In general, an epidural hematoma exceeding
30 cm 3 should be surgically evacuated regardless
the conscious level o the patient.
C. EDH maximal thickness > 3 mm on axial C
slices o the head is an absolute indication or
surgical intervention.
D. An acute rapidly expanding EDH is usually
evacuated in the operating room by two widely
spaced bur holes rather than a craniotomy.
E. Dural tenting/tack-up/hitching stitches (that
holds the dura to bone) should be avoided
because it may increase the risk o dural stripping
and post-operative EDH re-accumulation.

5. Regarding the complications and outcome o

Figure 73-3
cranial EDH, which o the ollowing is correct?
A. Patients with aSDH have a better prognosis and
outcome compared to those with EDH. 1. What type o intracranial hemorrhage did he
B. Rapidly expanding temporal EDH may cause have?
uncal herniation where the uncus compresses A. Epidural hemorrhage
the medulla oblongata medially. B. Subdural hemorrhage

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268 G EN ERAL S U RG ERY EXAM I N ATIO N AN D BO ARD REVI EW

C. Subarachnoid hemorrhage CASE 4

D. Hemorrhagic brain contusions
E. Intraventricular hemorrhage
2. Regarding this type o intracranial hemorrhage,
which o the ollowing is correct?
A. It occurs most commonly in the occipital and
parietal poles o the brain.
B. It occurs rom an impact o the brain on bony
prominences.
C. Surgical evacuation is only indicated in case o
progressive neurological deterioration.
D. emporal involvement has a lower threshold or
surgery than the other sites.
E. IV Dexamethasone is part o the medical man-
agement or this type o head injury.
A 26-year-old Hispanic male was brought to the emer-
gency room a er being involved in a motor vehicle acci-
dent 2 hours prior. He complained o an intense headache,
nausea, and was ound to have memory troubles. He was
a known cocaine addict. He was brought in by his room-
mate whom he could not identi y during examination.
T e patient had unremarkable vital signs and a GCS o
14/15. On neurological examination, he was agitated and
con used with post-traumatic amnesia. He had no appar-
ent motor or sensory de cit except or right sided pupil-
lary dilation and ptosis since the accident. A thorough
examination was done to exclude associated injuries and
a non-contrast C study o the head was done, which
revealed the image seen (Figure 73-4).

3. Regarding elevated intracranial pressure (= ICP)

and cerebral hemodynamics, which o the ollowing
is true?
A. Normal ICP o adults should always be less than
10 mm Hg.
B. reatment o high ICP should be initiated or
patients with sustained ICP 15 mm Hg.
C. T e goal o ICP management is to keep mean
ICP < 20 mm Hg and cerebral per usion pres-
sure (CPP) 70 mm Hg.
D. T e cerebral blood ow (CBF) to white matter is
higher than that o grey matter.

4. Which o the ollowing will increase ICP?

A. Mannitol 20% Figure 73-4
B. Saline 3%
C. Saline 23.4%
1. What is the most common cause o this type o
D. Dextrose 10%
intracranial hemorrhage?
E. Furosemide
A. rauma
B. Aneurysmal rupture
5. Which o the ollowing is considered to be routine C. Ruptured arteriovenous mal ormation (AVM)
measures to control ICP? D. Coagulopathy
A. Elevation o the head to 75 E. Pituitary apoplexy
B. Avoidance o hypotension, hypertension, or F. Cocaine abuse
hypoxia
C. Hyperventilation to keep PCO2 25 mm Hg 2. Regarding the clinical presentation o this type o
D. Heavy sedation and paralysis intracranial hemorrhage, which o the ollowing is
E. Endotracheal intubation or patients with GCS correct?
12 A. T e patient usually presents with high ICP symp-
toms secondary to hemorrhagic mass e ect and
not cytotoxic di use brain edema.

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 C H AP TER 7 3 H EAD IN j U RI ES 269

B. Seizures are not a part o the course o the disease.
C. Nuchal rigidity is mandatory to con rm the
diagnosis.
D. Patients do not present with ocal neurological
de cits.
E. Sudden onset unilateral ptosis with pupillary dila-
tion may raise the suspicion o cerebral aneurysm.
3. Regarding the diagnosis o this type o hemorrhage,
which o the ollowing is correct?
A. Lumbar puncture is a sa e procedure to con rm
the diagnosis by CSF analysis.
B. C Head requires IV contrast to increase the sen-
sitivity to 95% o cases within the rst 24 hours.
C. Contrast enhanced head C does not mimic the
radiological image o this type o intracranial
bleeding.
D. Fluid-attenuated inversion recovery (FLAIR)
MRI is the most sensitive MRI sequence to
detect bleeding.
E. MRI is a sensitive radiological study to detect the
acute stage (within the rst 24 hours) o this type
o bleed.
4. I this patient had no obvious history o head
trauma, what would be the gold standard study to
identi y the underlying cause o hemorrhage?
A. Magnetic resonance angiography (MRA)
B. Magnetic resonance venography (MRV)
C. Catheter cerebral angiography
D. MRI di usion study (DWI)
E. C per usion study
F. ranscranial doppler study
nausea, speech di culties, or visual changes. T e patient
reports several episodes o transient orthostatic light-
headedness and had had several alls; she ell last about
2 months prior to admission and had a minor head
trauma which was cared or without medical attention;
the patient denies loss o consciousness be ore or a er
the alls. During history taking, the patient reported that
she had a stroke 2 years ago which le her with slight
weakness in the le upper and lower extremities.
On physical examination her vital signs show BP
135/90 mm Hg; temperature o 98F (36.7C); RR o 16/
minute; HR is 76/minute and regular. Head, Eye, Ear,
Nose, and T roat Exam (HEEN ) is normocephalic
but showing a large bruise on her le temple. PERRLA
shows no undoscopic abnormalities. Her neck is supple,
with no carotid bruits and her heart rate and rhythm is
normal S1/S2, with no murmurs, rubs, or gallops.
T e neurological examination shows mental status
is alert and oriented 3. T e patient could spell words
backwards, but recalled only 2/3 objects. Her GCS is
11/15 and the cranial nerves are 212 grossly intact. Her
motor:strength is 5/5 in all muscle groups except 3/5 in
the le arm throughout. Her D Rs are asymmetric 3+
in le upper and lower extremities and 1+ on the right.
T ere was no Babinski sign bilaterally. T e cerebellar
exam was negative, as was Rombergs test. Her gait is nor-
mal and her sensation is intact to pinprick and light touch.
A thorough physical examination was done to exclude
skull bone ractures and spine injuries. Head C -scan
imaging showed the images provided below, revealing
a crescent shaped, hypo-dense extra-axial collection as
seen in Figure 73-5:

5. I the patients conscious level deteriorates, what

could be the underlying cause o this deterioration?
A. Hydrocephalus
B. Cerebral vasospasm
C. Hyponatremia
D. Rebleeding
E. Seizures
F. Any o the above

CASE 5
A 75-year-old emale was brought to the emergency
room by her daughter. T e patient has been complain-
ing o con usion, orget ulness, and headaches over the
last month and her symptoms got worse over the last
week. Her daughter, who lives with her, said that she has
not been hersel or about a month. She denies vomiting, Figure 73-5

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270 G EN ERAL S U RG ERY EXAM IN ATIO N AN D BO ARD REVI EW

T e patient was brought to the operating room or ANSWERS

evacuation o a hematoma. She did well post-opera-
tively and was discharged to rehabilitation at day-2 a er Answers to Case 1
surgery.
1. D. Image 73-1 is an axial cut o C head (bone win-
1. Which o the ollowing is considered to be the dow) showing a le parietal compound depressed
highest risk actor or chronic subdural hematoma bone racture. T is is a case o an open skull racture
af er head trauma? or compound depressed skull racture. It is recom-
mended to manage patients with skull ractures over-
A. Seizure history
lying a dural venous sinuses conservatively provided
B. Anticoagulation/antiplatelet therapy
that there is no neurological de cit or CSF leak. T e
C. Gender
high probability o vessel wall laceration with subse-
D. Alcohol abuse
quent pro use bleeding during surgery is the main
E. Age > 65
cause o perioperative mortality. Meier and his col-
leagues reported 100% mortality rate o cases with
2. Which o the ollowing statements is correct with skull ractures lacerating the posterior third o the
regard the options or management o chronic superior sagittal sinus and a 50% mortality rate in
subdural hematoma? cases in which the middle third was af icted. T e
A. Conservative treatment (e.g., corticosteroids and study showed an overall mortality rate o 41% or
bed rest) is suitable in lesions with less than 1 cm cases with major dural sinus injury. In a retrospec-
thickness even with the presence o ocal neuro- tive review o 27 patients with depressed compound
logic signs. skull ractures overlying but not disrupting a venous
B. Burr-hole drainage with the placement o subdu- sinus, a management recommendation was made that
ral drain is not as e ective as a craniotomy and wound washout with antibiotics is an adequate treat-
should be avoided. ment as long as there is no mass e ect or contamina-
C. Craniotomy is a suitable surgical intervention tion deep to bone. A depressed skull racture greater
or loculated lesions. than the thickness o the calvarium, an intracranial
D. Percutaneous twist-drill bedside drainage is not hematoma with mass e ect are considered possible
indicated because o the risk o in ection. indications o surgery.
E. Operating room twist drill craniostomy requires
intubation or heavy sedation. 2. B. T ere is no evidence that bone elevation ollow-
ing open skull ractures necessarily decreases the
3. Which o the ollowing correlates with the outcome incidence o post-traumatic seizures which probably
o chronic subdural hematoma? do occur as a direct result o the initial brain injury.
A. Hematoma density on C Early surgery has been recommended to reduce
B. raumatic etiology the risk o in ection but it does not e ect the extent
C. T e male sex o a traumatic brain injury. Antibiotics are part o
D. Hematoma location the management strategies o compound depressed
E. Age ractures. Same session cranioplasty or repair o
autologous bone is accepted only i there is no evi-
dence o in ection. Marked cosmetic de ormity may
4. Which o the ollowing risk actors is associated
warrant elective but not urgent surgical skull recon-
with higher recurrence rate o chronic subdural
struction.
hematoma (CSDH)?
A. Bilateral hematomas with poor re-expansion 3. A. Image 73-2 is an axial cut o C head (so tis-
rate a er surgery sue) shows a case o ension Pneumocephalus
B. Etiology with Mount Fuji sign due to collection o bi ron-
C. Interval rom trauma to rst operation tal subdural air compressing the brain. T is image
D. C -characteristics (density) depicts a case o tension pneumocephalus. Pneumo-
E. Age cephalus is de ned as the presence o air within the

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intracranial cavity and may include one or more o
the ollowing compartments: (a) epidural, (b) sub-
dural, (c) subarachnoid, (d) intraparenchymal, and/
or (e) intraventricular. ension pneumocephalus is
a term used when a considerable amount o air or
gas is detected on a C scan o the head with rapid
clinical deterioration. T is scenario usually war-
rants immediate surgical intervention in order to
avoid atal brain herniation. T e C here shows
accumulation o trapped air in subdural and inter-
hemispheric space with some resulting compress-
ing o the brain. T is radiological nding is called
Mount Fuji sign. T e air usually appears black on
C scans with a density measuring 1000 Houns-
eld units. No hydrocephalus is seen as there is no
ventricular enlargement. T e latter usually occurs
due to obstruction o the CSF- ow resulting in CSF
accumulation and subsequent ventriculomegaly
rom obstructive hydrocephalus. Hydrocephalus
ex vacuo is a term that alsely describes relative
ventricular enlargement that may occur in elderly
patients secondary to brain parenchymal atrophy
rom the natural aging process.
T e presence o a subdural hygroma is a post-
traumatic condition that develops due to a separation
o the dura-arachnoid inter ace ollowed by a passive
uid accumulation secondary to decreased ICP or
rom excessive dehydration. Such a uid collection
overlying the brain convexity rarely shows any mass
e ect which makes surgery usually unnecessary. T e
dynamics o alternating absorption and expansion is
thought to be responsible or the occasional trans or-
mation o some SDHG cases into chronic subdural
hematomas.
4. E. Most post-traumatic CSF leaks subside within
72 hours to 1 week without any need or surgical
intervention. Daele and colleagues recommended
surgery or spontaneous CSF stula cases since
they are more likely to persist. Post-traumatic CSF
otorrhea on the other hand usually stops within 5 to
10 days. Detection o 2-trans errin in rhinorrhea-
uid corroborates the presence o a CSF stula.
ahir and colleagues reported that C -cisternog-
raphy has the highest sensitivity and speci city
when compared to C - and MR-scanning to detect
the site o a CSF leak. Pneumococci are the most
common causative organisms in cases o menin-
gitis ollowing a CSF stula. Glucose urine strips
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C H AP TER 7 3 H EAD IN j U RI ES 271
could help in identi ying CSF due to its high glu-
cose concentration ( 40 mg/dl) when compared
to low glucose levels (< 5 mg/dl) ound in mucus
secretions.
Answers to Case 2
1. A. earing or avulsion o the bridging cortical veins
is one o the causes o aSDH. Hemorrhagic brain
contusions or lacerations might be another source
o aSDH. EDH is commonly caused by an arterial
injury o the middle meningeal artery which may
progressively strip the dura rom the inner table o
the skull. EDH is sometimes caused by bleeding rom
dural veins, venous sinus or diploic channel injury
ollowing skull ractures. In a case series o 40 in ants
with EDH, Leggate and colleagues could identi y the
bleeding source in 31 cases. In 42.5% o those cases
it was rom the middle meningeal artery. Skull rac-
tures were seen in 45% o cases in another series o
210 traumatic EDH cases.
2. E. T e alse localizing sign, or Kernohans notch
phenomenon, is a compression o the contralat-
eral cerebral peduncle against the edge o tentorial
incisura which can lead paradoxically to an ipsilat-
eral hemiparesis. It is an important motor localizing
sign that appears alse in topography, but may occur
with any supratentorial mass during uncal hernia-
tion. Yoo and colleagues explored this state o the
corticospinal tract in a patient with chronic SDH
and ipsilateral hemiparesis by using di usion tensor
imaging (D I) and transcranial magnetic stimula-
tion ( MS).
EDH occurs less requently in children and
elderly patients likely due to adherence o the dura
to the inner table o the skull, thus sealing rmly the
epidural space. In an epidemiological analysis o 210
cases o traumatic EDH, 89.2% o cases were in males
and the observed presenting GCS was between 13
and 15. T ere ore, it is not uncommon or patients
with EDH to be ully conscious at the time o clinical
assessment.
A classic lucid interval is seen in only 21% o
traumatic EDH cases. Ipsilateral pupillary dilation
mostly occurs ollowing oculomotor nerve compres-
sion by the medially displaced uncus and hippocam-
pal gyrus (called: uncal herniation).
In 27 posterior ossa EDH cases reported in a
study by Su and colleagues, headache and vomiting
272 G EN ERAL S U RG ERY EXAM I N ATI O N AN D BO ARD REVI EW
Figure 73-6 Axial cuts o C head. On the Right image: Rt acute subdural hematoma (crescentic and di use). On the Le
image: Rt acute epidural hematoma (lenticular and localized).
the most requently seen symptoms. Rapid brain-
stem compression with respiratory depression and
death may occur in posterior ossa EDH cases i not
treated promptly.
3. A. C scanning o the head usually shows a classic
appearance o EDH which is a homogeneous hyper-
dense extra-axial lenticular mass with convex bor-
ders. IV post-contrast C is very rarely needed in
cases o isodense EDH. EDH is usually localized to
a limited part o the calvarium since it is con ned by
the skull sutures (not the alx). On the other hand,
a SDH is characterized on head C as a crescentic
mass with biconcave shape, di usely spanning a large
area o the brain convexity and is not limited by the
sutures. T is is illustrated in Figure 73-6.
A swirl sign is a distinct radiographic sign o
active bleeding which may occur in di erent types
o intracranial hemorrhage. It presents as an area o
irregular density in the hyperdense clot and is typi-
cally o low attenuation (radiolucency). Its occur-
rence is associated with worse clinical outcomes and
bigger sizes o intracerebral hematomas as reported
by Selariu et al., as it represents an area o active
ongoing bleeding.
5. E. Uncal herniation usually occurs with mid-
4. B. An EDH measuring more than 30 cm 3 in volume
must be surgically evacuated regardless the GCS. A
midline shi o more than 5 mm is also a critical
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radiological sign o brain compression which usu-
ally indicates the need or surgical intervention. A
patient with a GCS o more than 8 and a hematoma
less than 30 cm 3, less than 15 mm in thickness, with
less than 0.5 cm midline shi , and without ocal
de cit can be managed by close observation with
serial scans and placement in a monitored neuro-
surgical unit. Acute intracranial hematomas are
evacuated by cranitomies or craniectomies as the
resh blood is almost clotted. On the other hand,
chronic SDH are usually liqui ed and can be surgi-
cally drained by one or two burr holes. Dural tent-
ing/tack-up/hitching stitches (that holds the dura
to bone) are advocated by many surgeons at the
end o the surgical procedure as a routine to close
the epidural space in order to prevent EDH reac-
cumulation. However, hemostasis is still the most
relevant aspect to prevent rebleeding and there is
no compelling evidence to support the role o dural
tenting or all intracranial operations.
Lumbar puncture may lead to li e threatening cen-
tral or tonsillar herniation in cases in which there is
high ICP and a pressure gradient between the intrac-
ranial and intraspinal compartments.
dle cranial ossa masses where the uncus herniates
medially compressing the occulomotor nerve, cer-
ebral peduncles o mid brain, and posterior cerebral

arteries which may cause unilateral ptosis with
mydriasis, hemiparesis, and hemianopia, respectively.
In a case series o 161 consecutive patients oper-
ated on or post-traumatic EDH, the overall mortal-
ity was 12%, which could be urther lowered by early
diagnosis and proactive management. T e overall
mortality in another study o aSDH was 66%. T e
Cushings triad is a re ex triggered by markedly
elevated ICP causing hypertension, bradycardia, and
respiratory irregularities. Delayed EDH is de ned as
a radiologically evolving EDH during sequential neu-
roradiologic examination and which was not present
initially. Detection o a skull racture is an indication
or hospital admission under neurologic observation
or early detection o possible delayed EDH.
Answers to Case 3
1. D. Image 73-3 is an axial cut o C head shows mul-
tiple hemorrhagic brain contusions (le rontal and
bitemporal). T is is a case showing a right temporal
hemorrhagic brain contusion. It is also called di use
post-traumatic intracerebral hemorrhage and usu-
ally appears on C scanning during the immediate
post-traumatic phase as an intra-axial hyperdensity
indicating resh blood within the brain parenchyma.
2. D. T e degree o temporal involvement o en plays
a critical role due to its proximity to the brain stem,
whereas mass e ect is better tolerated in a ected
supratentorial brain areas. T ere ore, the development
o temporal hematomas carries a lower threshold or
surgical intervention. T e indications or surgery in
cases o traumatic brain contusions include hema-
toma causing progressive neurological deteriora-
tion; signs o signi cant mass e ect on C ; medically
re ractory intracranial hypertension; patients with
GCS scores o 6 to 8 with a rontal or temporal contu-
sion greater than 20 cm 3 in volume and with a midline
shi o at least 5 mm and/or cisternal compression on
C scan, and patients with any lesion greater than 50
cm 3 in volume. Patients with such eatures should be
treated operatively with decompression and possible
resection o the a ected area.
Cerebral contusions most requently develop a er
a mechanical impact o distinct skull areas onto the
rather so brain substance in moments in which
the brain bounces. Frontal and temporal lobe tips
are most commonly a ected by such ocal hemor-
rhagic contusions ollowing translational accel-
eration. Glucocorticoids are not recommended to
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C H AP TER 7 3 H EAD I N j U RI ES 273
improve the outcome or lower the ICP in patients
with severe traumatic brain injury.
3. C. ICP is one o the most power ul predictors o
neurological outcome in patients with traumatic
brain injury. Normal values are variable among di -
erent age groups and are shown in the ollowing
table:
Age Group Normal Range (mm Hg)
Adults <1015
Children 37
erm in ants 1.56
Variable thresholds have been suggested or the
initiation o treatment or raised ICP in patients
with head injury. Most neurosurgical centers use a
sustained ICP 2025 mm Hg. An intraventricu-
lar catheter is the most accurate way o monitor-
ing. T e goal o ICP management is to keep it below
20 mm Hg provided that the CPP is not lowered
below 50 mm Hg (not 70 mm Hg) to guard against
cerebral ischemia.
CBF = CPP / CVR = (MAP - ICP) / CVR
CBF is the cerebral Blood Flow
CVR is the Cerebrovascular Resistance
MAP is the Mean Arterial Pressure
CPP is the Cerebral Per usion Pressure
ICP is the Intracranial Pressure
T e average cerebral blood ow usually ranges
rom 50 to 60 mL/min/100 g o brain tissue during
resting state. Normal white matter receives 1825 mL/
min/100 g, while normal gray matter receives 67
80 mL/min/100 g.
4. D. Hyperglycemia aggravates cerebral edema. Brain
cell swelling is increased by hyperglycemia and keto-
sis especially during hypocapnia. T ere ore, Dextrose
10% is not considered appropriate in cases o head
trauma as it will urther increase the ICP impeding
both the CPP and CBF. Osmotic medical therapy
includes mannitol and/or hypertonic saline (used
to control the ICP in traumatic brain injury). Furo-
semide is a loop diuretic that can result in greater
reduction o brain water content i administered in
combination with mannitol as it enhances its e ect
on plasma osmolality.
2 74 G EN ERAL S U RG ERY EXAM I N ATIO N AN D BO ARD REVI EW
5. B. It is not recommended to use hyperventilation
vigorously to lower PaCO2 to less than 25 mm Hg
as a PaCO2 o less than 30 mm Hg may lower the
CBF or distort cerebral autoregulation without con-
sistently lowering ICP. T e goal is to keep PaCO2 at
the lower end o eucapnia (35 mm Hg). T e other
options that are considered routine measures to con-
trol ICP are head o bed elevation to 30, light seda-
tion, intubation or a GCS < 8.
Answers to Case 4
1. A. Image 73-4 is an axial cut o C head shows di -
use post-traumatic subarachnoid hemorrhage. T is
is a case o subarachnoid hemorrhage (SAH) shown
in the C in the orm o a hyperdense blood lm in
the subarachnoid cisterns. rauma is still the most
common cause o SAH. Aneurysmal rupture is the
most common cause o spontaneous SAH. Ruptured
AVM usually presents in the orm o intracerebral
hemorrhage or intraventricular hemorrhage. SAH
occurs in about 5% o AVM cases. Other causes
may include pituitary apoplexy, coagulopathy, and
cocaine abuse.
2. E. Nuchal rigidity may occur in some cases o SAH
due to meningeal irritation but it is not a must
or diagnosis. Patients with SAH may present with
increased ICP symptoms, seizures and/or neurologi-
cal de cit. Unilateral ptosis with pupillary dilation may
indicate occulomotor nerve compression secondary
to a posterior communicating artery (P-comm) aneu-
rysm. Nine percent o P-comm aneurysms present
with unilateral occulomotor nerve palsy, which may
indicate impending rupture and prompt intervention
by a specialized neurovascular team. Cytotoxic brain
edema is usually seen in head trauma patients (vs.
vasogenic brain edema in brain tumor cases).
3. D. Lumbar puncture always carries the risk o re-
bleeding in case o aneurysmal SAH. T ere ore, LP
is only needed to con rm the diagnosis o clinically
suspicious cases o SAH with negative or equivocal
C scans. Sidman et al. reported that C scans o the
head had 100% sensitivity in detecting SAH within
the rst 12 hours. Morgenstern and his colleagues
stated that 97.5% o patients with SAH present-
ing to the emergency room with worst headache
symptoms were adequately diagnosed by C imag-
ing alone. MRI is valuable in demonstrating subacute
and chronic hemorrhages due to Methemoglobin
ormation which may determine the source o bleed-
ing in patients with multiple cerebral aneurysms. T e
FLAIR sequence has the highest sensitivity in detect-
ing the cases with low-grade SAH. 2* / Gradient echo
sequence or Susceptibility Weighted Image (SWI)
may be done as a complementary sequence. Post-
contrast C o the head may be misdiagnosed as SAH
especially i the contrast is injected intrathecal.
4. C. T e our-vessel cerebral angiogram or catheter
cerebral angiography is the gold standard study or
the evaluation o cerebral aneurysms. C angiog-
raphy (C A) with 3-dimensional reconstruction
imaging may be used instead o catheter angiogra-
phy in some centers as the sole imaging diagnostic
study be ore major surgical intervention. C A is a
non-invasive tool that may provide prompt, accurate,
and versatile diagnostic and anatomical in ormation
on which clipping can be based. However, unneces-
sary craniotomies based exclusively on C A ndings
were also reported.
MRA can also detect cerebral aneurysms, but it
has lower sensitivity and speci city compared to
the catheter cerebral angiogram especially or aneu-
rysms less than 3 mm diameter. MRA is also use ul in
screening high-risk patients. MRI Di usion (DWI)
is the best imaging study or detection o acute brain
ischemia within the rst hours especially when it
involves the brain stem or cerebellum. C per usion
identi es the area surrounding the in arction called
potentially salvageable penumbra that allows or
better outcomes i interventional treatment modali-
ties are available. ranscranial doppler ( CD) is a
non-invasive semi-quantitative technique o ultra-
sound derived blood velocity measurements within
major cerebral vessels (e.g., MCA) through thin
regions o skull bones providing a window. CD is
usually used in SAH to detect cerebral vasospasm
early prior to the clinical delayed ischemic neuro-
logical de cit. T eoretically, the higher the velocity
o blood ow, the narrower the lumen o the cerebral
blood vessel.
5. F. SAH has numerous possible complications that
may cause neurological deterioration. It is believed
that proteinaceous blood products may occlude the
arachnoid granulations causing secondary commu-
nicating hydrocephalus in 20% o SAH survivors.
Angiographic cerebral vasospasm is a contributing
actor o delayed neurological de cit in patients with

SAH. Broderick and his colleagues reported on the
causes o morbidity and mortality ollowing aneu-
rysmal SAH. In their study, re-bleeding was the most
important preventable cause o death.
It is also well-known that seizures may occur early
ollowing SAH mostly due to the presence o blood
in the cisterns which may irritate the cerebral cor-
tex, but the explanation o late onset seizures remains
unclear. T e prevalence rate o hyponatremia ollow-
ing SAH is about 30% to 55%. Hyponatremia may
lead to seizures, vasospasm, altered mental status,
or death. It may occur due to syndrome o inappro-
priate ADH (SIADH) secretion or glucocorticoid
de ciency. However, correction o hyponatremia
should always be gradual and monitored, as rapid
corrections may cause central pontine myelinolysis
(osmotic demyelinating syndrome).
Answers to Case 5
1. B. Image 73-5 is an Axial cut o C head shows right
rontoparietal chronic subdural hematoma. Patients
with chronic anticoagulation/antiplatelet therapies
are considered to be at high risk or chronic subdural
hematoma rom trivial traumas. T ose patients are
prone to develop subdural bleeding within days or
weeks a er small head trauma. T e mechanism is
not yet very well understood, although alteration
in the blood-hematoma components was ound in
most anticoagulation treated patients.
For answer A, although patients with uncon-
trolled seizure episodes are more prone to requent
head traumas rom potential recurrent seizure epi-
sodes, those patients dont have higher incidence o
subdural hematomas a er trivial trauma compared
to patients with chronic anticoagulation therapy. For
answer C, there is higher incidence o chronic sub-
dural hematoma in male compared to emale, but
gender does not seem to in uence the development
o CSDH a er slight head trauma. In answer D, his-
tory o alcohol abuse associated with coordination
and motor problems, consequently more alls, that
put the patient at risk or recurrent head trauma. But
history o alcohol abuse does not show a strict corre-
lation with CSDH a er trauma as coagulation thera-
pies do. For answer E, although old people (e.g., age
> 65 years) have a higher incidence o CSDH com-
pared to those with age < 65, age is not considered
a risk actor or the development CSDH a er head
trauma.
C H AP TER 7 3 H EAD IN j U RI ES 275
2. C. Conservative treatment including bed-rest and
corticosteroids have been shown to be very e cient
in the treatment o patients with hematoma less
than 1 cm without ocal neurologic de cit or mental
status changes. Corticosteroids have been posited
as both an anti-in ammatory and anti-angiogenic
agents. Answer B, Burr-hole drainage with the
placement o subdural drain, was shown to decrease
signi cantly the recurrence rate o CSDH a er
treatment. Answer C, Craniotomy with excision o
subdural membranes, is indicated when the hema-
toma persistently recurs despite the treatment with
twist-drill craniostomy or burr hole drainage. It has
been shown to be sa e and valid technique. Answer
D, Percutaneous twist-drill bedside drainage, is the
least invasive technique over the above mentioned
techniques. It requires a 0.5 cm incision in the scalp
and has been shown to be a sa e technique. Operat-
ing room twist drill craniostomy, answer E, is a valid
option or the management o CSDH, although, it
does not o er any advantage over the percutaneous
twist-drill drainage in terms o recurrence. How-
ever, given that CSDH is more requent among the
elderly, the treatments diverge regarding the periop-
erative risks related to general anesthesia; burr holes
are requently per ormed under general sedation,
whereas a local anesthetic is usually su cient with
percutaneous drainage, so patients comorbidities
have to be taken in consideration.
3. A. Brain atrophy, hydrocephalus, midline shi , and
hematoma density on C (e.g., high, iso, or low) all
in uence the outcome o CSDHs. raumatic causes,
sex, hematoma location and age have never been
shown to correlate with CSDHs outcome.
4. A. T e presence o bilateral e usion and poor re-
expansion is associated with high rate o recurrence.
For answers B, C, D, E, etiology (e.g., alcoholism,
head injury, neurosurgery, anticoagulant, coagulopa-
thy, subarachnoid cyst), interval rom trauma to rst
operation, C - ndings (e.g., high, iso, or low den-
sity), and age are not associated with higher recur-
rence o rate o CSDH a er surgery.
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 74
NeurosurgeryHyponatremia/
Hypernatremia
Albert Jesse Schuette
A 38-year-old male presents to the trauma bay with a
Glasgow coma scale (GCS) o 15 ollowing a motor vehi-
cle crash. T e patient undergoes a computed tomogra-
phy (C ) scan o the head that shows a small traumatic
subarachnoid hemorrhage over the right rontal lobe
and tiny contusions in the right rontal and le occipi-
tal lobes. Overnight the patient becomes slightly more
agitated but his GCS remains stable at 15. A C scan the
morning a er admission shows no change in his intrac-
ranial injuries. Additionally, his chemistry panel the ol-
lowing morning shows a sodium level o 130 mEq/L.
His admission sodium was noted to be 139 mEq/L.
1. A er determining that the ef ective serum
osmolality was within the normal range and
urine osmolality was greater than 100 mOsm/kg,
the next step in determining the cause o the
hyponatremia is:
A. Assess the patients volume status.
B. Determine the liver unction and cardiac output.
C. Check pituitary unction assays or cortisol
derangements.
D. Draw an arterial blood gas to determine the pH
o the blood.
E. Determine the urine sodium level.
2. Your team has determined that the patient is
euvolemic and has given him the diagnosis o
syndrome o inappropriate antidiuretic hormone
secretion (SIADH). His sodium on last draw was
128. On last exam, the patient shows no symptoms
o hyponatremia. What treatment would you begin
to correct the low serum sodium level?
A. Fluid bolus
B. Hypertonic saline
C. Fluid restriction
D. Vaptan therapy
E. IV steroid dose
3. Which o the ollowing statements is true regarding
the neurological signs and symptoms associated
with severe hyponatremia?
A. Usually not apparent until Na drops below
115 mEq/L.
B. I the hyponatremia is chronic (> 48 hours in
duration), the patient will be symptomatic.
C. I symptoms are present, the physician should
rapidly correct the sodium to near normal levels
at a rate o 57 mEq/L/hr.
D. Symptoms typically include headache and poor
concentration.
E. Hyponatremia can be atal due to transtentorial
herniation.
4. T e patients neurological exam has now deteriora-
ted requiring intubation, external ventricular drain
placement, and aggressive intracranial pressure
(ICP) management. T e patients urine output has
increased to over 300 cc/hr and the serum sodium
has increased to over 150 mOsm/hr. What diagnosis
would you assign the patient at this time and what is
the likely cause?
A. Nephrogenic diabetes insipidus due to medica-
tions
B. Neurogenic diabetes insipidus due to undiag-
nosed skull racture
280 G EN ERAL S U RG ERY EXAM I N ATI O N AN D BO ARD REVIEW
C. Neurogenic diabetes insipidus due to herniation
D. Neurogenic diabetes insipidus due to underlying
meningitis
E. Nephrogenic diabetes insipidus due to underly-
ing kidney disease
5. Which o the ollowing is part o the best treat-
ment option or this patient?
A. Monitor uid intake and output hourly and draw
the serum sodium every 24 hours.
B. Place on a basal uid rate with D5 NS with
replacement or urine output above the base rate.
C. Administer DDAVP rst and assess impact on
urine output.
D. Allow the patients thirst mechanism to control
the Na level and treat with DDAVP as needed.
ANSWERS
1. A. T e diagnosis or the cause o hyponatremia is
generally reached in an algorithmic ashion. A er
a lab measurement shows serum sodium less than
135 mEq/L, you must determine the ef ective serum
osmolality. T is rules out hyperglycemia, hypertri-
glyceridemia, and hyperproteinemia (so called pseu-
dohyponatremia). T e next step is to evaluate urine
osmolality to ensure that the patient is not suf ering
rom water intoxication. A er these three steps are
complete, the patients volumes status must be ascer-
tained. T is is extremely important in a neurologic
patient as it will help dif erentiate the most com-
mon neurologic causes o hyponatremia: syndrome
o inappropriate antidiuretic hormone secretion
(SIADH) and cerebral salt wasting (CSW).
2. C. As with the diagnosis, the treatment or SIADH
also runs as an algorithm. Again, the patient must be
con rmed to be euvolemic as the treatment or CSW
involves uid resuscitation and or SIADH o en
involves uid restriction. In the case o a patient with
mild hyponatremia (125135 mEg/L) with no symp-
toms, treatment should involve uid restriction. I
there are symptoms, patients should receive saline
in usion with 0.9% saline and Lasix. Finally, in cases
with Na levels less than 125 mEq/L and symptoms,
patients are treated 3% saline and Lasix. Newer med-
ications such as the vaptan class, which act as a vaso-
pressin antagonist, can be used in re ractory cases.
3. E. T is question relates to the symptoms and gen-
eral treatment options o hyponatremia. T e neu-
rologic symptoms o mild hyponatremia or chronic
hyponatremia involve headache, poor concentra-
tion, anorexia, and muscle weakness. T e more acute
and severe hyponatremia cases can lead to cerebral
edema, nausea, seizures, respiratory arrest, coma,
and death rom transtentorial herniation. Symptoms
generally are easily diagnosed below 125 mEq/L.
Symptoms are more apparent with acute onset
(< 48 hours in duration) as there is less time or
mechanisms o the brain to compensate. For that rea-
son, chronic hyponatremia (> 48 hours) can be rela-
tively asymptomatic even at low Na levels. T e rate
o correction even in symptomatic and acute cases
should not exceed 1 to 2 mEq/L/hr and 810 mEq/L
in 24 hours to avoid central pontine myelinolysis.
4. C. Hypernatremia is de ned as a serum sodium
> 150 mEq/L. In patients with neurologic injuries,
this is commonly due to diabetes insipidus (DI). DI
is due to low levels o ADH or renal insensitivity to
ADH. T e diagnosis can be reached by high output o
inappropriately dilute urine with high serum osmo-
lality and high serum sodium. T e two major eti-
ologies are neurogenic DI and nephrogenic DI. T e
primary causes o nephrogenic DI are medications,
renal disease, hypokalemia, and hypercalcemia. Neu-
rogenic DI can be idiopathic, posttraumatic, tumors,
in ections, vascular, and autoimmune. In a posttrau-
matic patient who has worsening mental status, the
cause is most likely due to herniation rom pituitary
stalk injury or hypothalamic injury rom impending
brain death.
5. B. A er arriving at the diagnosis o central diabe-
tes insipidus, it is essential to begin treatment o the
patient. T e treatment o DI is based around anti-
diuretic hormone (ADH) analogues. T ese include
Pitressin and the longer acting, more potent orm,
DDAVP. In a conscious and ambulatory patient,
o en their thirst mechanisms will compensate or
the hypernatremia. However, the patient in this
scenario is unable to drink or compensate with his
thirst mechanism, so D is clearly incorrect. I the
patient is not able to drink, they should be monitored
or Is and Os q1h with serum sodium draws every
6 hours. o deal with the uid loss, the patient should
be placed on a basal uid rate with D5 NS with
replacement or urine output above the base rate. I
the uid replacement continues to all behind and
the hypernatremia worsens, Pitressin or DDAVP
 C H AP TER 7 4 N EU RO S U RG ERY H YP O N ATREM I A/ H YP ERN ATREM IA
may be given. T ough all the possible answers are
treatments or DI, only the rst three could be uti-
lized or this patient.
BIBLIOGRAPHY
Adrogue HJ, Madias NE. Hyponatremia. T e New England
journal of medicine. May 25, 2000;342(21):15819.
Chanson P, Salenave S. reatment o neurogenic diabetes
insipidus. Annales dendocrinologie. December 2011;72(6):
4969.
2 81
Greenberg MS. Handbook of neurosurgery. New York, NY:
T ieme Publishing Company; 2010.
Maghnie M. Diabetes insipidus. Hormone research. 2003;
59(1):4254.
Peri A, Giuliani C. Management o euvolemic hyponatremia
attributed to SIADH in the hospital setting. Minerva endo-
crinologica. March 2014;39(1):3341.
Petersen RC. Acute con usional state. Dont mistake it or
dementia. Postgraduate medicine. December 1992;92(8):
1418.
 75
Ophthalmology rauma
Morohunranti O. Oguntoye and Robert A. Mazzoli
T ere is an ammonium nitrate explosion at a local er-
tilizer plant, with multiple injured persons and atalities
at the scene. Pre-hospital EMS providers, rst respond-
ers, and bystanders begin to administer rst aid to the
injured and start trans er o patients to the local hos-
pital. As the on-call emergency medicine physician,
you and your colleagues stand ready in the emergency
department while preparing or a potential mass casu-
alty event. As part o the report or incoming injuries,
you are noti ed that there are multiple ace and eye
injuries. T e on-call ophthalmologist is on his way, but
he is being delayed by the tra c that was caused by the
explosion. You have been designated to manage oph-
thalmic injuries until he arrives.
1. A 35-year-old male involved in the explosion was
splashed in the ace with ammonia. His ace was
irrigated with water at the scene, but he complains
o persistent eye pain and decreased vision.
T e rst priority in the initial care o the patient
should be?
A. Obtaining visual acuity
B. Neutralization o pH with an acidic solution
C. Copious irrigation with non-caustic solution
D. Obtaining eye pressure
E. Pain control
2. You examine a 45-year-old emale worker who
ell during the explosion, striking her eye on the
side o a work bench. On gently retracting the
lids, the globe appears so and irregular with
di use subconjunctival hemorrhage and swelling.
She can only count ngers with that eye. You
suspect a ruptured globe and begin management
until the ophthalmologist arrives. Which o the
ollowing would be contra-indicated in the initial
management o this patient?
A. Ultrasound
B. Fox Shield/Rigid Eye Shield
C. Antibiotics
D. X-Ray/C
E. etanus shot
3. A worker is hit in the le eye/orbit with a large
piece o ying debris. T e patient is in severe pain,
and is unable to open his eye. Gentle palpation o
the le eye reveals a markedly swollen orbit that
is dif cult to retropulse. T e eyelids are tense
but you are able to gently open the lids with a
retractor. Vision is light perception only. You note
the pupil dilates when you shine light in it, but the
contralateral pupil then constricts as you swing the
light to it. Extraocular motility is severely limited.
What is your diagnosis and plan or management?
A. Open globelateral canthotomy and cantholysis
B. Orbital blowout ractureorbital decompres-
sion
C. Retrobulbar hemorrhagepressure patch in
anticipation o surgical intervention
D. Retrobulbar hemorrhagelateral canthotomy
and cantholysis
E. Periorbital ecchymosisice packs and pain con-
trol
4. T ere is an elementary school next to the ertilizer
plant. A 7-year-old child was struck in the right ace

and orbit with ying debris, resulting in a brie loss o
consciousness. He has minimal bruising on his ace
and he has no complaints other than mild discom ort
around that eye. As you conduct your exam, you note
that he avoids looking at you, pre erring to keep his
eyes shut. His vision, intraocular pressure (IOP), and
pupil exam appear normal, but when you instruct
him to look up as part o the exam, he immediately
vomits. You continue your exam and note that his
heart rate drops dramatically whenever you ask him
to move his eyes, prompting you to discontinue the
exam. You suspect an orbital racture but the eye
and lid are otherwise unremarkable. What is your
concern and urgency?
A. Intracranial hemorrhage: emergent
B. Orbital oor (blowout) racture: emergent
C. Orbital oor (blowout): non-urgent
D. Retrobulbar hemorrhage: emergent
E. Carotid dissection: non-urgent
5. T e on-call ophthalmologist has called to get an
update on the patients you have seen. Which o the
ollowing physical exam or imaging techniques
would be indicated or the given pathology?
A. Best corrected visual acuity in a retrobulbar
hemorrhage.
B. Relative a erent pupillary de ect (RAPD) with
an open globe injury.
C. Intraocular pressure exam in a chemical burn.
D. Ultrasound when computerized tomography
(C ) scan is not available in a suspected globe
rupture.
E. C scan o orbit and brain with intraorbital or-
eign body.
ANSWERS
1. C. A chemical injury is a true ophthalmic emer-
gency. While visual acuity and IOP are the vital
signs o ophthalmology, in the case o a chemical
injury, diluting and removing the chemical agent
takes priority. Copious but gentle irrigation with any
non-caustic uid should begin in the prehospital set-
ting and continue at the hospital until the pH o the
ocular sur ace has normalized to between 7.0 and
7.2. In an emergency department setting, Lactated
Ringers or normal saline are the pre erred uids or
irrigation, but tap water can be used, i necessary.
Irrigation should last or at least 30 minutes and may
require several liters o irrigant.
C H AP TER 7 5 O P H TH Al m O l O g y TRAu m A 283
I there is any suspicion or an open globe, irri-
gation should be gentle but thorough and tap water
should be avoided because o potential intraocular
damage. Never use acidic solutions to neutralize
alkalis or vice versa, as these can generate harm ul
substrates. opical anesthetic can be used to acilitate
the irrigation process and provide the patient some
com ort, but it should not delay care. A lid speculum
may be necessary to keep eyes open or irrigation.
Upper and lower eyelid ornices should be everted
and irrigated. Particulate matter should be ushed
out or manually removed. T e conjunctival ornices
should be swept with moistened cotton-tipped appli-
cators to remove any particles or caustic materials.
Check the pH in the ornices 5 to 10 minutes af er
irrigation and resume irrigation i the pH is not
within the normal range. Retained material should
be suspected i the pH remains abnormal.
T e pH should be rechecked 15 to 30 minutes af er
stabilization. It is also important to identi y the chem-
ical agent and the time o the injury. Alkali materials
(e.g., sodium hydroxide/lye, ammonia, calcium
hydroxide/lime, industrial/chemical detergents)
cause more damage to the eye than acidic materi-
als due to deeper penetration. Once the pH has been
neutralized, a ull eye exam should be conducted.
Worrisome ndings or extensive damage include:
signi cantly decreased visual acuity (irrigation itsel
may cause a temporary keratitis and mild decrease
in vision), increased IOP, partial and ull-thickness
burns to the surrounding skin, conjunctival swelling,
conjunctival blanching, ull thickness penetration/
open globe, and an opaque cornea. A shield should
be applied and the patient trans erred to an ophthal-
mologist immediately or urther care.
2. A. A history suspicious or open globe will of en
include a blunt or penetrating trauma to the eye,
a eeling o loss o uid rom the eye, pain, and
decreased vision. Determining whether there is an
open globe is one o the most important aspects o
the ocular trauma evaluation, as this requires metic-
ulous initial care to prevent additional injury and an
emergent evaluation by an ophthalmologist. Signs
that are concerning or open globe include a sof or
irregular-appearing globe, an irregular or peaked
pupil, hemorrhagic swelling o the conjunctiva (espe-
cially i 360 degrees), positive Seidels sign on the
cornea (leakage o uid seen upon staining with uo-
rescein), hyphema (blood in the anterior chamber),
284 g EN ERAl S u Rg ERy EXAm IN ATI O N AN D BO ARD REVIEW
Figure 75-1 Signs o open globe af er blunt trauma to the eye:
irregular pupil, at anterior chamber, and leakage o intraocu-
lar uids rom the eye. Note the examiners nger positioning,
minimizing pressure on the globe. Source: Dr. Morohunranti
O. Oguntoye.
a shallow or deep anterior chamber (compared to
the uninjured eye), decreased extraocular motility,
oreign body tract, and severe vision loss.
Figure 75-1 shows a patient who presented to the
emergency department af er being hit in the eye with
a branch. He complained o uid leakage rom his
eye, mild to moderate eye pain, and decreased vision.
Note the irregular, cloudy pupil, at anterior cham-
ber, and the leakage o intraocular uids (vitreous) at
the 5 oclock position o the eye. Also note the exam-
iners nger positioning, with the ngers at the brow
and maxilla used to hold open the eye. T is allows
or a proper examination without applying pressure
to the globe, which could lead to urther extrusion o
intraocular contents.
Once the diagnosis o an open globe is made, ur-
ther examination should be de erred to the ophthal-
mologist, who can address the injury at the time o
surgical repair. A visual acuity may be obtained (light
perception, hand motion, count ngers are appro-
priate measures i the patient cannot see letters on
a near card) but measurement o IOP should not
be attempted. No pressure should be applied to an
eye with a suspected open globe, to include an ultra-
sound probe, especially when other clinical ndings
strongly point to the diagnosis and disposition. Ask
the patient not to strain or squeeze their eyelids. Do
not remove any penetrating objects.
A rigid eye shield should be applied over the
patients eye to prevent urther injury. I a rigid eye
shield is not available, alternatives include the bottom
o a paper cup, moldable splints (e.g., SAM splints),
or sunglasses/eye protection. Do not apply patches
or gauze pads to an open globe. Do not use topical
anesthetics or ointments. Anti-nausea medications
should be given with any pain medications to pre-
vent Valsalva and/or vomiting. Imaging (pre erably
an axial ace and orbit C scan with coronal recon-
structions) should be obtained to rule out concomi-
tant injuries or unidenti ed retained oreign bodies.
Antibiotics should be given within 6 hours o the
injury (4th generation uoroquinolones IV have
excellent vitreous penetration are pre erred in adults;
Ce azolin 25 to 50 mg/kg/day IV in 3 divided doses
and Gentamicin 2 mg/kg IV q8h or children). A tet-
anus shot should be given i necessary. Remember-
ing how to deal with an open globe can be acilitated
by using the acronym FAC : Fox shield, Antibiotics/
Anti-emetics/Analgesia, C scan, and etanus shot.
T e eye should be shielded and the patient should be
trans erred immediately to the nearest ophthalmolo-
gist or urther care.
3. D. In a patient who has had recent blunt trauma
or surgery to the eye/orbit, ndings o intense pain,
decreased vision, an RAPD (the a ected pupil para-
doxically dilates to light, while the normal pupil con-
stricts to it), inability to open eyelids due to swelling,
and loss o color vision should raise a strong sus-
picion or retrobulbar hemorrhage, which is a true
ocular emergency. In contrast to the open globe, the
exam will reveal a tense, proptotic globe that is resist-
ant to retropulsion on gentle palpation. In the case
o an orbital blowout racture, the globe is usually
enophthalmic (sunken in) and there is pain on eye
movement, but the visual acuity is usually normal
or only slightly decreased. A patient with periorbital
ecchymosis (black eye) may have some periorbital
tenderness and swelling but should not have globe
proptosis, signi cantly elevated eye pressure, or vis-
ual acuity changes.
Retrobulbar hemorrhage is an orbital compart-
ment syndrome that can rapidly and permanently
damage the optic nerve and retina leading to perma-
nent vision loss i not identi ed and treated immedi-
ately. T e retinas ischemic tolerance time is roughly
90 minutes. Retrobulbar hemorrhage is a clinical
diagnosis and does not require any additional imag-
ing. T e key to e ective management o a retrobulbar
hemorrhage is timely and aggressive decompression
 C H AP TER 7 5 O P H TH Al m O l O g y TRAu m A 285

Figure 75-2 Steps to per orm a lateral canthotomy and cantholysis. (A) injection o local anesthe-
sic, (B) Crush the lateral canthus with straight hemostat, (C) Divide the lateral canthon tendon,
(D) Pull the lower eyelid away rom ace and divide the in erior crus o the canthal tendon, (E)
Divide any remaining attachments so lower eyelid pulls away reely rom ace (Modi ed and
Reproduced rom Department o De ense. Ocular injuries. In: Emergency War Surgery Manual.
4th ed. San Antonio, exas: Borden Institute; 2013:14.8).

with a lateral canthotomy and cantholysis by the rst
provider that is able to per orm the decompression
(see Figure 75-2). T e goal is to disinsert the lower
eyelid sling rom its periosteal attachments at the
lateral canthus. T e only two instruments needed are
tissue orceps, and blunt scissors. I available, local
anesthetic and a hemostat can acilitate a smoother
procedure.
A detailed description o lateral canthotomy and
cantholysis is ound within the article Emergency
lateral canthotomy and cantholysis: A simple proce-
dure to preserve vision rom sight threatening orbital
hemorrhage, by Ballard, et al. Following a success-
ul lateral canthotomy and cantholysis, additional
measures to reduce the orbital pressure should be
instituted, including applying ice packs to the orbit,
elevation o the head, and administration o systemic
analgesia and anti-emetics.
4. B. T is is what is known as a white-eyed blow
out racture or trapdoor racture with oculocar-
diac re ex, and represents an ocular emergency.
286 g EN ERAl S u Rg ERy EXAm I N ATIO N AN D BO ARD REVI EW
Childrens bones are exible, and their orbital bones
can break and bend, allowing the rectus muscle to
pass below the broken but non-displaced bone. T is
can result in a racture in which the rectus muscle is
trapped below what appears to be an intact orbital
oor. T e external signs can be minimal: T ere may
be no periorbital edema but the patient will exhibit
signi cant extraocular muscle restriction. A child
will of en not complain o double vision, rather he
may simply close one or both eyes.
T e oculocardiac re ex can occur when extraocu-
lar muscles are pulled. Immediate signs and symp-
toms can include nausea, vomiting, and bradycardia
with eye movement. Bradycardia can be so pro ound
as to cause syncope or asystole. T e mani estation o
this re ex is an ocular emergency and an ophthal-
mologist should be consulted immediately or de ni-
tive management.
Adults with orbital oor ractures will complain o
pain on attempted eye movement, binocular vertical
diplopia, and hypoesthesia in the distribution o the
in raorbital nerve V2 (ipsilateral cheek and upper lip).
Signs may include enophthalmos, crepitus, subcutane-
ous emphysema, restricted eye movement, nosebleeds,
bony point tenderness, and step-o de ormities o the
orbital rim. I the patient had an intracranial hemor-
rhage, dilated pupils and rapidly declining mental sta-
tus should be expected. A retrobulbar hemorrhage or
carotid dissection would cause an RAPD. Periorbital
ecchymosis should not cause vomiting and/or brady-
cardia. While orbital blowout ractures in children can
be an ocular emergency, in adults without an RAPD
or oculocardiac re ex, ophthalmic re erral can be
delayed up to 24 to 48 hours. An RAPD, ashes, oat-
ers, photophobia, or decreased vision should prompt
an immediate ophthalmic consult.
5. E. Ultrasound is contraindicated in an open globe
because pressure on the globe may lead to extrusion
o intraocular contents. T e initial visual acuity in
an open globe correlates with trauma severity and is
highly predictive o nal visual outcome. T e RAPD
in a patient with a retrobulbar hemorrhage indicates
ocular compartment syndrome, requiring emergent
decompression. Fluorescein exam in a chemical burn
indicates the extent o the corneal damage. In the
case o penetrating ocular or orbital injury, a C scan
should always be obtained to determine the location
o intraorbital oreign bodies and to rule out optic
nerve or central nervous system involvement.
An eye exam can be broken down into a primary
survey (identi ying sight-threatening injuries) and
a secondary survey (the complete ophthalmic
exam). T e primary survey is per ormed using a
muscle light/penlight, uorescein with Woods lamp,
a visual acuity card, an intraocular pressure (IOP)
instrument, and an ophthalmoscope. T e secondary
survey is per ormed using a slit lamp and an oph-
thalmoscope.
Key ndings on the primary survey include:
Best corrected visual acuity: Count ngers (CF),
hand motion (HM), and no light perception (NLP)
rom best to worst i the patient is unable to visualize
the ar or near charts.
IOP: not elevated (> 21) or decreased (< 10) (Note:
do not per orm i suspecting open globe).
Globe: well formed, no leakage of uid, free extraoc-
ular motility, no proptosis, not tense to retropulsion,
no oreign bodies, enophthalmos/exophthalmos, no
oculocardiac re ex.
Cornea: uorescein exam without evidence of up-
take or leakage, no corneal clouding, no oreign bod-
ies [NB: contact lenses should be removed].
Conjunctiva: no swelling, no blanching, no subcon-
junctival hemorrhage.
Anterior chamber: well formed, no in ammation, no
blood (hyphema).
Pupil: reactive to light and accommodation, not
peaked/irregular/torn.
Posterior segment: no optic nerve swelling, no vitre-
ous hemorrhage.
Key ndings on the secondary survey:
Orbit/Globe: crepitus, step-o s/deformities, numb-
ness on cheek, teeth, or orehead.
Lids: laceration, medial canthus rounding, canalicu-
lar lacerations, epiphora, tense lids, ecchymosis, or-
nix evaluation, singed lashes.
Conjunctiva: laceration.
Cornea: corneal edema.
Iris: iris tears, photophobia.
Anterior segment: lens dislocation.
Posterior segment: retinal detachment.
BIBLIOGRAPHY
Ballard S, Enzenauer R, et al. Emergency lateral canthotomy
and cantholysis: A simple procedure to preserve vision
rom sight threatening orbital hemorrhage. Journal o
Special Operations Medicine. 2009;9:2632.

Gerstenblith A , Rabinowitz MP. T e Wills eye manual: Of ce
and emergency room diagnosis and treatment o eye disease.
Philadelphia, PA: Lippincott Williams & Wilkins, 2012.
Hemmati HD, and Colby KA. Ophthalmic pearls: Cornea.
treating acute chemical injuries o the cornea. San Francisco,
CA: American Academy o Ophthalmology EyeNet Maga-
zine; October 2012.
C H AP TER 7 5 O P H TH Al m O l O g y TRAu m A 287
Joint T eater rauma System Clinical Practice Guide-
line. Initial care o ocular and adnexal injuries by non-
ophthalmologists at Role 1, Role 2, and non-ophthalmic
Role 3 Facilities. CEN COM. November 2014.
Lima Vanessa, et al. Orbital compartment syndrome: the
ophthalmic surgical emergency. Survey o Ophthalmology.
July-August 2009;54:441441.
 76
T oracic rauma
Booker . King
1. A 22-year-old male who sustained a gunshot
wound to the chest arrives in the emergency room
at your acility. He is hemodynamically stable and
has an entry wound just below his right nipple and
probable exit wound just below the tip o the le
scapula. Supine chest lm shows no retained bullet
ragments, contusion o the lung and moderate le
apical pneumothorax. A pericardial ultrasound
shows no ef usion or other abnormality. T e initial
diagnostic work-up and management o this injury
should include:
A. Computerized tomography angiogram (C A) o
the chest a er placement o le chest thoracos-
tomy tube.
B. Placement o le thoracostomy tube and obser-
vation on the ward.
C. rans-esophageal echocardiogram, non-contrast
C scan o the chest, and le chest thoracostomy
tube.
D. Bronchoscopy, esophagoscopy, esophagography,
a catheter angiogram o the thoracic aorta, and
le chest thoracostomy tube.
E. Immediate surgical exploration via a median
sternotomy.
2. A 50-year-old male is brought to a local
emergency room a er a motor vehicle collision.
He is complaining o mild mid-sternal chest pain
and has some bruising over the sternum. He is a
healthy male with no cardiac history. C scan o
the chest, abdomen, and pelvis are unremarkable.
Electrocardiogram shows normal sinus rhythm
with a heart rate o 65 bpm. What is the most
appropriate management o this patient?
A. Admission to the intensive care unit with serial
cardiac panel and repeat chest lm in 24 hours.
B. Echocardiogram per ormed in the emergency
room to evaluate cardiac wall motion.
C. Discharge home with instructions to return to
the hospital i the symptoms worsen.
D. Consultation with cardiologist or suspected
acute coronary syndrome.
E. Repeat C scan o the chest in 12 hours.
3. A 33-year-old emale was admitted a er being
involved in a motor vehicle collision ve days ago.
She had a le chest tube placed upon admission
or a hemothorax. Initially, 150cc o blood was
evacuated but a er 24 hours, only additional 100cc
came out. A repeat C scan o the chest now shows
a retained hemothorax and there has been minimal
drainage rom the chest tube or the past 48 hours.
T e most appropriate management o this patient
at this time would be:
A. Video assisted thorascopic surgery (VA S) to
evacuate the hemothorax.
B. VA S i hemothorax does not resolve in three
more weeks o observation.
C. Instill thrombolytic agent into the chest cavity
via the chest tube to break up the clot.
D. T oracotomy or decortication and evacuation
o hemothorax.
E. C scan guided aspiration o retained hemo-
thorax.
 C H AP TER 7 6 TH o RAC i C TRAu m A 289

4. A 21-year-old male sustained multiple injuries ANSWERS

a er he struck a tree while riding a motorcycle
traveling at 60 mph. He was intubated at the scene 1. A. Although the majority o thoracic gunshot wounds
or unresponsiveness. He was transported to will be localized to one side o the thoracic cavity, it
your medical center and trauma evaluation was is critical to identi y the smaller subgroup o patients
signi cant or a 2 cm right-sided rontal cerebral with a trans-mediastinal trajectory. rans-medias-
contusion, racture o ribs 2 through 6 on the tinal gunshot wounds carry a signi cantly higher
right, right clavicle racture and moderate right mortality and morbidity, and can present a diagnos-
pulmonary contusion. A right-sided chest tube was tic and management dilemma due to the number o
placed or large pneumothorax. Repeat chest lm critical structures at risk o injury. Unstable patients
shows a persistent pneumothorax so a second chest require immediate intervention and surgical explo-
tube was placed. A third set o chest lms show that ration based on the initial examination and imaging
the lung has re-expanded slightly but a moderate ndings. Stable patients require urther radiologic
apical pneumothorax remains. T e two chest tubes workup, with the goal o excluding injury to the heart,
have a persistent large air leak present. T e next lungs, great vessels, esophagus, and tracheobronchial
step in this patients management should be: tree. Historically this mandated an exhaustive series
o imaging studies including chest X-ray or C scan,
A. Oxygenate with 100% oxygen or 24 hours to
echocardiogram, esophagoscopy and esophagogra-
allow pneumothorax to resolve spontaneously.
phy, thoracic angiography, and bronchoscopy.
B. Repeat chest lm in six hours and planned VA S
With the improved availability and image quality
i pneumothorax persists.
obtained with modern C scanners, this exhaustive
C. Urgent bronchoscopy.
workup has largely been replaced by a single high-
D. Continued observation as long as the patient is
quality C scan o the chest with intravenous con-
stable and oxygenating well.
trast in most trauma centers. In addition to imaging
E. T oracotomy or repair o probable large paren-
the critical mediastinal structures o interest, the
chymal lung laceration.
C scan can be used to re-create the missile tract
5. An 80-year-old male sustained multiple bilateral and assess the proximity to these structures and to
rib ractures and a mild pulmonary contusion a er identi y any secondary signs o injury (Figure 76-1).
a motor vehicle collision. He is hemodynamically Patients with a negative C scan can be sa ely
stable and oxygenating well in the emergency observe, while those with any concern or a potential
room but complains o chest pain upon deep
inspiration. rauma evaluation did not reveal any
other injuries. T e appropriate management o
this patient should be:
A. Discharge to home on oral pain medications and
instructions to return to the hospital i his condi-
tion worsens.
B. Admission to medical-surgical ward with sup-
plemental oxygen and orders or repeat chest
lms in 12 hours.
C. Admission to intensive care unit, pain control
with either a thoracic epidural or patient con-
trolled analgesia (PCA) with ketorolac, and
incentive spirometry.
D. Admission to intensive care unit and schedule
operative xation o rib ractures or the ollow- Figure 76-1 Chest C scan o a transmediastinal gunshot
ing day. wound shows the key mediastinal structures as well as the
E. Admission to intensive care unit and electively trajectory and tract o the missile. (Reprinted courtesy o
intubate the patient as he is at signi cant risk or Aydemir NA, Bakir I, Atin F et al. A magic bullet through the
respiratory ailure. heart. Circulation. 2007;115:e4678.)
290 G EN ERAL S u RG ERY EXAm i N ATi o N AN D Bo ARD REVi EW
injury can then undergo additional ocused evalua-
tion based on the C scan results. T is patient has a
le pneumothorax and thus a le tube thoracostomy
should be placed prior to obtaining the C scan.
Immediate operative exploration is not indicated
in the stable patient with no other obvious signs o
injury to a mediastinal organ or structure.
2. C. T is patient presents with mild symptoms a er
motor vehicle collision. Cardiac contusion should
be suspected but unlikely given clinically presen-
tation and normal electrocardiogram. Serial car-
diac panel could yield mildly elevated enzymes but
not clinically relevant data. Echocardiogram would
not be indicated either given normal electrocardio-
gram. Cardiology consult is not necessary since the
patients symptoms are not related to myocardial
ischemia. A repeat C scan o the chest will likely
show no changes. T is patient can be sa ely dis-
charged home.
3. A. T is patient has a retained hemothorax. T ere is
a signi cant risk or this patient to develop a compli-
cated uid collection, brothorax, or empyema i the
hemothorax is not evacuated in a timely manner. T e
instillation o thrombolytic agents into the chest cav-
ity or C scan guided aspiration o hemothorax may
not result in complete evacuation o the hemotoma
since much o the hemotoma is probably solidi ed
clot at this point. Patients who received early VA S
(within 5 days) had lower incidence o developing
empyema in several studies. T oracotomy would not
be warranted at this time since the hemothorax can
be evacuated less invasively with VA S. C guided
drainage is an option but a signi cant portion o the
hematoma has clotted; there ore, this will not likely
be an e ective therapy.
4. C. T e patient has sustained signi cant chest
trauma but tracheobronchial injury must be ruled
out given persistent pneumothorax. T is is particu-
larly true in the presence o a large and persistent
air leak and inability to re-expand the lung despite
adequate mechanical ventilation and chest tube
drainage. An urgent bronchoscopy will be needed
to evaluate or a tracheobronchial injury that may
require intervention or surgical repair. It would not
be wise to per orm a blind thoracotomy until bron-
choscopy is per ormed rst to identi y and localize
the injury. Observation is particularly dangerous in
this situation since even a brie period o hypoxia is
not tolerated well in a patient with traumatic brain
injury. 100% oxygen therapy is usually reserved or
non-traumatic pneumothoraces.
5. C. T e patient is an elderly male who sustained chest
trauma resulting in multiple rib ractures and pulmo-
nary contusion. T is patient is at a high risk or pul-
monary complications, pneumonia, and death i not
managed appropriately and aggressively. T e patient
should be admitted to the intensive care unit or close
monitoring and pain management. Elderly patients
o en have limited physiologic reserve and unrecog-
nized decompensation on a medical-surgical ward
could have tragic implications. Pain control with
either a thoracic epidural in usion or intravenous/
oral narcotics supplemented with a non-steroidal
anti-in ammatory agent such as ketorolac should be
initiated, and titrated to allow ull inspiratory e ort
without pain. Intubation should not be done until the
patient has ailed conservative management (includ-
ing in selected cases a trial o non-invasive ventilator
support). Operative xation o rib ractures is usually
reserved or patients who are dif cult to wean rom
mechanical ventilation, and would not be indicated
this early a er the initial injury.
BIBLIOGRAPHY
Aydemir NA, Bakir I, Atin F, et al. A magic bullet through the
heart. Circulation. 2007;115:e4678.
Dubose J, Inaba K, Demetriades D, et al. Management o post-
traumatic retained hemothorax: A prospective, observa-
tional, multicenter AAS study. J rauma Acute Care Surg.
Jan 2012;72(1):1122.
Embrey R. Cardiac trauma. T orac Surg Clin. Feb 2007;
17(1):8793, vii.
Harrington D , Phillips B, Machan J, et al. Factors associ-
ated with survival ollowing blunt chest trauma in older
patients: results rom a large regional trauma cooperative.
Arch Surg. May 2010;145(5):4327.
Kiser AC, OBrien SM, Detterbeck FC. Blunt tracheobron-
chial injuries: treatment and outcomes. Ann T orac Surg.
2001;71:205965.
Martin RS, Meredith JW. Management o acute trauma. In:
ownsend CM, Beauchamp RD, Evers BM, Mattox K, eds.
Sabiston extbook of Surgery: T e Biological Basis of Mod-
ern Surgical Practice. 19th ed. Philadelphia, PA: Elsevier
Saunders;2012:449.
Okoye O , alving P, eixeira PG, et al. ransmediastinal
gunshot wounds in a mature trauma centre: Changing per-
spectives. Injury 2013; 44(9):11981203.
 77
Sepsis and Multi-Organ Failure
Robert Shawhan, Matthew Eckert, and Matthew J. Martin
A 68-year-old emale is brought into the emergency
department by her son or evaluation o altered mental
status. T e son reports that his mother rarely goes to the
doctor, is an alcoholic, and has been a smoker as long
as he can remember. She has occasionally had intermit-
tent bouts o diverticulitis that have been treated with
oral antibiotics. Her most recent bout was 2 weeks ago
or which she recently nished a course o antibiot-
ics. For the past two days she has had requent stools
and increasing abdominal pain over the past 48 hours.
oday she was noted to be somnolent and di cult to
arouse by her son.
On exam, her vitals show a temperature o 101.8F,
with a heart rate o 121. Her blood pressure is 83/54 and
respiratory rate o 24, O2: 83% on RA. She is lethargic,
lungs are coarse bilaterally; her abdomen is distended,
and she grimaces with palpation o her lower abdomen.
Her skin is pale and cool, and she has at neck veins.
Labs are signi cant or a white blood cell count (WBC)
o 24, creatinine o 3.2, and lactate o 5.8. An arterial
blood gas is obtained that pH o 7.30, pCO2 o 80, and
pO2 o 67 with a base de cit o 10. Her central venous
oxygen saturation (ScvO2) is 55%.
1. T e patient is intubated and trans er to the
intensive care unit (ICU) is being arranged. Which
o the ollowing is true regarding the initiation o
goal directed therapy?
A. Antibiotic therapy should be delayed until all
cultures are obtained and a causative organism is
identi ed.
B. Normalization o blood lactate is a poor guide
or resuscitation.
C. Goals o early goal directed therapy in sepsis are
to achieve a central venous pressure (CVP) 8 to
12 mm Hg; urine output 0.5 mL/kg/hr; and
ScvO2 o 70% or greater.
D. In intubated patients, a higher CVP (12 to
15 mm Hg) should be considered pathologic.
E. Early initiation o targeted goal directed ther-
apy in sepsis has not been de nitively shown to
improve survival.
2. Despite receiving 3 liters o crystalloid, the patient
remains hypotensive with a systolic blood pressure
o 75 and a ScvO2 o 60. Her hematocrit is 41%.
Which o the ollowing is the appropriate next
step?
A. Switch to using a hydroxyethyl starch solutions
as they are considered equivalent to isotonic
crystalloid in the resuscitation o septic patients,
and are use ul in patients in uid re ractory
shock.
B. Start a high dose phenylephrine in usion and
titrate to a MAP o 65 mm Hg.
C. Initiate a Levophed (norepinephrine) in usion
and i the patient remains hypotensive consider
starting a low dose vasopressin in usion.
D. Start an in usion o intravenous hydrocortisone.
E. Obtain an echocardiogram to determine i the
patient is in cardiogenic shock prior to initiating
a vasopressor.
3. Initial cultures were sent on admission. Because
o a recent history o antibiotic use and diarrhea,
a polymerase chain reaction (PCR) based
292 G EN ERAL S U RG ERY EXAM I N ATIO N AN D BO ARD REVI EW
clostridium dif cile toxin test was sent as well.
Despite initiating broad spectrum antibiotics
the patient remain in shock. welve hours a er
admission the labs calls and tells the nurse that the
test is positive or clostridium dif cile (C. dif cile)
toxin. Which o the ollowing statements is true
regarding the management o this patient?
A. Repeat the test or C. dif cile because PCR based
tests have a high alse positive rate.
B. In addition to broad-spectrum antibiotics, anti-
ungal agents should be routinely started on
admission o septic patients.
C. A er a patient is asymptomatic, low pro brain
natriuretic peptide can help the decision to dis-
continue antibiotics.
D. Surgical intervention or this pathology would
include a total abdominal colectomy and end
ileostomy.
E. Once a source o in ection is identi ed, source
control should be initiated a er antibiotics have
taken ef ect and the patient is no longer septic.
4. Upon arrival to the ICU a chest X-ray is obtained
and is shows bilateral inf ltrates. T e ventilator is
set to assist control mode with a peep o 5, tidal
volume o 8 cc/kg, and FiO2 o 60%. On these
setting her most recent PaO2 is 55. You suspect
acute respiratory distress syndrome (ARDS).
Which o the ollowing is true regarding ARDS?
A. ARDS requires the presence o a ocal and uni-
lateral in ltrate or consolidation on chest X-ray.
B. In patients with ARDS, routine corticosteroid
use has been shown to reduce the overall mortal-
ity rate compared to placebo.
C. Use o high tidal volumes and low positive end-
expiratory pressure (PEEP) is the traditional
ventilator strategy used to ventilate patients with
ARDS.
D. reatment options or re ractory ARDS that has
ailed conventional ventilation include airway
pressure release ventilation (APRV), high re-
quency ventilation, and extra-corporeal mem-
brane oxygenation (ECMO).
E. Airway pressure release ventilation has been
shown to improve mortality in patients with
ARDS.
5. In patients treated or septic shock, there are
consequences o a prolonged ICU stay and can
include progressive dys unction and even ailure
o multiple organ systems. Regarding outcomes
o multi-organ dys unction syndrome (MODS),
which o the ollowing is true?
A. For septic patients that develop agitation and
delirium, the use o benzodiazepines has been
shown to reduce length o ICU stay, making
them pre erred over other agents.
B. Acute kidney injury is an independent risk actor
or death in patients with multi-organ dys unc-
tion syndrome.
C. Because septic patients are hypermetabolic,
parental nutrition has been shown to be bene -
cial when initiated early.
D. Stress ulcer prophylaxis with proton-pump
inhibitors is not associated with any adverse
events or complications.
E. Critical illness polyneuropathy does not result
in di culty weaning a patient rom a ventilator
because it results in peripheral nerve dys unc-
tion but preservation o the diaphragm.
ANSWERS
1. C. T e main principles o sepsis therapy are to begin
both treatment and resuscitation immediately upon
identi cation o sepsis or suspected sepsis. reat-
ment should consist o early initiation o empiric
broad spectrum antibiotics and initial antibiotic
administration does not require identi cation o
the exact causative organism. When sepsis is sus-
pected early initiation o resuscitation with the goal
o reversing tissue induced hypoper usion has been
shown to improve patient survival in patients pre-
senting with septic shock. T e goals o resuscitation
should be to achieve a CVP 812 mm Hg, MAP
65 mm Hg, urine output 0.5 mL/kg/hr, and ScvO2
o 70% or SvO2 o 65% within 6 hours. In mechani-
cally ventilated patients venous return can be
impeded and as a result a higher target or CVP (12
to 15 mm Hg) is recommended. Note that there is no
arbitrary systolic blood pressure as a primary goal o
resuscitation.
Lactate is also a marker o metabolic acidosis and
tissue hypoper usion, and is seen in a majority o
patients presenting in septic shock. When a patient
presents with hypotension and an elevated lactate
(4) they have an increased mortality over elevated
lactate or hypotension alone. I a patient presents
with an elevated lactate it can be monitored until it
reaches normal levels and can be used along with
 C H AP TER 7 7 S EP S I S AN D M U LTI - O RG AN FAILU RE
other markers, to guide resuscitation. Base de cit
is another measure o metabolic acidosis that may
be used to gauge the severity o illness and to guide
resuscitation. It is o en used as a surrogate or lac-
tate, but there are many other actors that can impact
the base de cit (renal ailure, alcohol, bicarbonate
losses), making it a less speci c measure o tissue
hypoper usion and lactic acidosis.
In addition to restoring tissue hypoper usion, a
source o the patients sepsis should be sought and
appropriate antibiotics should be administered. Each
hour antibiotics administration is delayed results in a
measurable increase in patient mortality. Ideally, cul-
tures should be obtained prior to giving antibiotics
with the goal o administering antibiotics within one
hour o presenting with sepsis. However i obtain-
ing appropriate cultures would delay the administra-
tion o antibiotics beyond one hour, then antibiotics
should be given prior to obtaining cultures.
2. C. Many studies have been conducted comparing
synthetic starches to isotonic crystalloid based solu-
tions. T e results o these studied have varied. Some
studies have shown no mortality dif erence, others
have shown increased mortality or increased rates
o renal replacement therapy. None have shown a
bene t, and recent data suggest increased renal ail-
ure and mortality with administration o hydroxy-
ethyl starch solutions. T ere is also a concern or the
potential impact o these solutions on platelet unc-
tion and coagulation. As a result, starch-based solu-
tions are not recommended or resuscitation.
Vasopressor therapy is recommended or use
in hypotensive septic patients a er adequate vol-
ume resuscitation to maintain per usion pressures.
Norepinephrine (Levophed) is currently the initial
vasopressor o choice or septic shock, as it pro-
vides a balanced pressor and cardiac inotrope ef ect.
Dopamine is associated with increased short-term
mortality and serious adverse events compared to
norepinephrine. Pure vasopressors such as phenyle-
phrine should be avoided as the unopposed vasocon-
striction can o en urther worsen the ongoing tissue
hypoper usion and lead to severe extremity or bowel
ischemia. I the patient remains hypotensive a er
starting norepinephrine then starting a low dose
in usion o vasopressin at 0.03 U/min can be used
to decrease the dose o norepinephrine and enhance
organ per usion. I the patient remains in septic
shock despite uids and appropriate vasopressor
293
therapy then corticosteroid administration can be
considered.
Based on the presentation, there is a high suspicion
o septic shock and no clinical or physical exam signs
o cardiogenic shock. While an echocardiogram may
be use ul in certain situations, the treatment or sep-
tic shock should not be delayed. Delaying treatment
o septic shock and can result in increased patient
mortality.
3. D. T is patient has a C. dif cile in ection and likely
toxic megacolon secondary to the in ection. PCR
based C. dif cile toxin as well as most current test or
C. dif cile are extremely sensitive and speci c or the
diagnosis o an active C. dif cile in ection and repeat
testing is not necessary. T e severity o C. dif cile
in ections can range rom mild to severe. In very
severe cases, patients can present with shock and
sepsis known as ulminant C. dif cile colitis or toxic
megacolon. Over the past two decades this diagno-
sis has become more common, and more and more
patients are requiring surgical intervention.
While we do not know rom the description i
there is per oration or peritoneal signs, this patient
is clearly in shock. Antibiotic therapy should be
targeted at the suspected diagnosis and the patient
should be immediately evaluated or surgical inter-
vention. Surgical intervention or toxic megacolon
rom any cause typically mandates resection o the
entire colon (total abdominal colectomy) and place-
ment o an end ileostomy. Anti- ungal agents should
not be routinely started in septic patients. T ey
should be used only in patients that are at risk o or
suspected o having a ungal in ection. Patients that
are immunocompromised, neutropenic, or live in at
risk areas should be considered or the implementa-
tion o anti- ungal agents. However, there is nothing
in this patients history that would lead us to suspect
she is at an increased or a ungal in ection.
Once a source o in ection is identi ed then anti-
microbial therapy should be targeted at the suspected
source. I there a speci c anatomical source o in ec-
tion such as an abscess, cholangitis, and so on, that
is driving a patients sepsis, then emergent-targeted
therapy should be initiated within 12 hours; not a er
antibiotics have taken ef ect. However, i no source o
in ection is identi ed and the patient improved with
empiric anti-biotic therapy, then procalcitonin levels
(not pro BNP levels) can be used to help a clinician
determine when to stop anti-microbial therapy.
294 G EN ERAL S U RG ERY EXAM I N ATI O N AN D BO ARD REVIEW
4. D. In 2012, an updated clinical de nition o ARDS
(known as the Berlin De nition) was published. T e
presence o bilateral chest opacities is needed to make
the diagnosis o ARDS, and either a chest radiograph
or a C scan is an acceptable way to evaluate or this.
A ocal unilateral in ltrate or consolidation on chest
X-ray would be more consistent with lobar pneumo-
nia than ARDS. According to the most recent ARDS
de nition outlined by the ARDS task orce the diag-
nosis o ARDS must be made within one week o a
known clinical insult, and typically the diagnosis is
made within 72 hours. A er the diagnosis is made,
the use o low tidal volumes (4 to 6 mL/kg) should be
initiated as this is the only mode o ventilation shown
to improve mortality in randomized controlled trials
o patients with ARDS. As part o this strategy, high
PEEP is o en utilized to increase alveolar recruit-
ment and improve oxygenation, but has not been
shown to improve overall mortality.
Many other strategies are utilized to try and
improve outcomes in patients with re ractory ARDS.
One treatment that has been studied is the use o cor-
ticosteroids. T e ARDSNet trial showed that while
corticosteroids reduced then mean number o days
on a ventilator and increased the number o shock-
ree days, they had no ef ect on overall survival and
were harm ul when given more than two weeks a er
the diagnosis o ARDS was made. Meduri et al. used
low dose corticosteroids, and while ICU mortality
was signi cantly reduced overall mortality was not.
For the patient in ARDS who is re ractory to stand-
ard mechanical ventilation, salvage or rescue options
include switching to APRV, high requency or jet
ventilation, and even ECMO. Other rescue therapies
include prone positioning, neuromuscular blockade,
and inhaled nitric oxide. While these treatments are
used as rescue therapies in severe ARDS and have
been shown to produce improved oxygenation, they
have not been shown to improve mortality in con-
trolled trials.
5. B. T ere are many challenges that are encountered
when managing a critically ill patient, and delirium
is a commonly encountered complication in the ICU
setting. Severely ill and older patients are at particu-
larly high risk or developing delirium, and this has
been shown to adversely impact morbidity and mor-
tality. While benzodiazapenes are ef ective or delir-
ium acutely, their use has been shown to increase ICU
length o stay and as a result they should be avoided
whenever possible. Rather the primary treatment
or agitation and delirium is non-pharmacologic
and includes reorientation and maintenance o
sleep-wake cycles. I this is in-ef ective then anti-
psychotics such as haloperidol or the newer atypical
antipsychotics are pre erred to benzodiazepines.
Another area that can challenge the manage-
ment o septic patients is predicting which patients
are likely to have a worse outcome. T ere are many
scoring systems that are utilized to predict out-
come in these patients, including the well-described
APACHE score. One such system that is speci c or
multi-organ ailure is the Sequential Organ Failure
Assessment or SOFA score. T is system indepen-
dently grades the severity o organ dys unction or
6 dif erent organ systems: respiratory, coagulation,
liver, cardiovascular, central nervous system, and
renal. T e individual scores are then added to give
a total score.
Higher overall SOFA scores directly correlate with
a worse outcome (Figure 77-1). Mortality has been
shown to directly increase with the number o organ
systems that are ailing, and approaches 100% when
4 or more organ systems have ailed. Among individ-
ual organ systems, one o the strongest predictors o
ICU morbidity and risk o mortality is the develop-
ment o acute kidney injury and/or renal ailure.
Many critically ill patients are at increased risk
o upper gastrointestinal bleeding, and stress ulcer
prophylaxis is indicated or patients with prolonged
mechanical ventilation (>48 hours) or other risk ac-
tors. T e risk o bleeding rom stress ulceration or
gastritis in this patient population must be weighed
against the risk o treatment with either proton pump
inhibitors (PPI) or histamine receptor blockers (H 2
blockers). Multiple studies have shown that patients
that receive stress ulcer prophylaxis are at increased
risk o adverse events and complications such as
C. dif cile in ections, ventilator associated pneumo-
nia, and thrombocytopenia (H 2 blockers).
Although hypermetabolism and a prolonged cat-
abolic state are characteristic o sepsis and MODS,
there has been no demonstrated survival bene t
o administration o parenteral nutrition. Multi-
ple series have demonstrated that overall in ectious
complications are lower among patients given enteral
nutrition versus total parenteral nutrition, and the
gut should be the pre erred route or nutritional sup-
port whenever possible. Another important problem
that is seen in patients with septic shock is critical
 C H AP TER 7 7 S EP S I S AN D M U LTI - O RG AN FAILU RE 295

Figure 77-1 Graph demonstrating the association o higher sequential organ ail-
ure assessment (SOFA) scores with mortality at all time points during ICU admis-
sion. (Reprinted with permission rom Fueglistaler P, Amsler F, Schuepp M, et al.
Prognostic value o sequential organ ailure assessment and simpli ed acute physi-
ology II score compared with trauma scores in the outcomes o multiple-trauma
patients. Am J Surg. 2010;200:204214.)

illness polyneuropathy. T e highly morbid condi-
tion is more common in patients with prolonged
ICU stays and among patients who received steroids
and/or neuromuscular blocking agents. It can pre-
sent with muscle atrophy, limb weakness, peripheral
sensory de cits and di culty weaning patients rom
mechanical ventilation. However, cranial nerve unc-
tion is usually spared.
BIBLIOGRAPHY
T e Acute Respiratory Distress Syndrome Network. Venti-
lation with lower tidal volumes as compared with tradi-
tional tidal volumes or acute lung injury and the acute
respiratory distress syndrome. N Engl J Med. 2000;342(18):
13018.
Adhikari NKJ, Dellinger RP, Lundin S, et al. Inhaled nitric
oxide does not reduce mortality in patients with acute
respiratory distress syndrome regardless o severity: Sys-
tematic review and meta-analysis. Crit Care Med. 2014;
42(2):40412.
Brower RG, Lanken PN, MacIntyre N, et al. Higher versus
lower positive end-expiratory pressures in patients with
the acute respiratory distress syndrome. N Engl J Med. 2004;
351(4):32736.
Cohen SH, Gerding DN, Johnson S, et al. Clinical practice
guidelines or Clostridium di cile in ection in adults:
2010 update by the society or healthcare epidemiology
o America (SHEA) and the in ectious diseases society
o America (IDSA). In ect Control Hosp Epidemiol. 2010;
31(5):43155.
De Backer D, Aldecoa C, Njimi H, Vincent JL. Dopamine
versus norepinephrine in the treatment o septic shock: a
meta-analysis. Crit Care Med. 2012;40(3):72530.
De Backer D, Biston P, Devriendt J, et al. Comparison o dopa-
mine and norepinephrine in the treatment o shock. N Engl
J Med. 2010;362(9):779789.
Delaloye J, Calandra . Invasive candidiasis as a cause o sep-
sis in the critically ill patient. Virulence. 2014;5(1):1619.
Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis
Campaign: international guidelines or management o
severe sepsis and septic shock, 2012. Intensive Care Med.
2013;39(2):165228.
Ferreira FL, Bota DP, Bross A, Mlot C, Vincent JL. Serial eval-
uation o the SOFA score to predict outcome in critically ill
patients. JAMA. 2001;286(14):17548.
Friedrich O. Critical illness myopathy: Sepsis-mediated ail-
ure o the peripheral nervous system. Eur J Anaesthesiol
Suppl. 2008;42:7382.
Girard D, Bernard GR. Mechanical ventilation in ARDS:
A state-o -the-art review. Chest. 2007;131(3):9219.
doi:10.1378/chest.06-1515
Guidet B, Martinet O, Boulain , et al. Assessment o hemody-
namic e cacy and sa ety o 6% hydroxyethylstarch 130/0.4
versus. 0.9% NaCl uid replacement in patients with severe
sepsis: T e CRYS MAS study. Crit Care. 2012;16(3):R94.
Heyland DK, Johnson AP, Reynolds SC, Muscedere J. Procal-
citonin or reduced antibiotic exposure in the critical care
setting: A systematic review and an economic evaluation.
Crit Care Med. 2011;39(7):17929.
Marik PE, Vasu , Hirani A, Pachinburavan M. Stress ulcer
prophylaxis in the new millennium: A systematic review
and meta-analysis. Crit Care Med. 2010;38(11):22228.
296 G EN ERAL S U RG ERY EXAM IN ATIO N AN D BO ARD REVI EW
Maung AA, Kaplan LJ. Airway pressure release ventilation in
acute respiratory distress syndrome. Crit Care Clin. 2011;
27(3):5019. doi:10.1016/j.ccc.2011.05.003
Meduri GU, Golden E, Freire AX, et al. Methylprednisolone
in usion in early severe ARDS results o a randomized con-
trolled trial. 2007. Chest. 2009;136(5 Suppl):e30.
McConnell KW, Coopersmith CM. Organ ailure avoidance
and mitigation strategies in surgery. Surg Clin North Am.
2012;92(2):30719, ix.
Myburgh JA, Fin er S, Bellomo R, et al. Hydroxyethyl starch or
saline or uid resuscitation in intensive care. N Engl J Med.
2012;367(20):190111.
Perner A, Haase N, Guttormsen AB, et al. Hydroxyethyl starch
130/0.42 versus Ringers acetate in severe sepsis. N Engl J
Med. 2012;367(2):12434.
Ranieri VM, Ruben eld GD, T ompson B , et al. Acute respi-
ratory distress syndrome: the Berlin De nition. JAMA.
2012;307(23):252633.
Rivers E, Nguyen B, Havstad S, et al. Early goal-directed
therapy in the treatment o severe sepsis and septic shock.
N Engl J Med. 2001;345(19):136877.
Russell JA. Bench-to-bedside review: Vasopressin in the man-
agement o septic shock. Crit Care. 2011;15(4):226.
Sprung CL, Annane D, Keh D, et al. Hydrocortisone therapy or
patients with septic shock. N Engl J Med. 2008;358(2):11124.
Stanley JD, Bartlett JG, Dart BW, Ashcra JH. Clostridium di -
cile in ection. Curr Probl Surg. 2013;50(7):30237.
Steinberg KP, Hudson LD, Goodman RB, et al. E cacy and
sa ety o corticosteroids or persistent acute respiratory
distress syndrome. N Engl J Med. 2006;354(16):167184.
Vincent JL, de Mendona A, Cantraine F, et al. Use o the
SOFA score to assess the incidence o organ dys unction/
ailure in intensive care units: Results o a multicenter, pro-
spective study. Working group on sepsis-related problems
o the European Society o Intensive Care Medicine. Crit
Care Med. 1998;26(11):1793800.
 78
Major Burns and Smoke Inhalation
ovy Haber Kamine, Stephen R. Odom, and Booker . King
A 25-year-old man arrives in the emergency depart-
ment a er being pulled rom a house re. On initial
evaluation in the emergency room, he is noted to be
agitated, with singed hair around his mouth and cough-
ing up black sputum. T e right hal o his torso and
back are covered with thick leathery skin, as are his
right arm, thigh, and leg. His right arm is burned cir-
cum erentially. T e le hal o his torso and back are
erythematous, with no blisters. His vital signs are show-
ing a temperature o 95.3F with a heart rate o 120/
min. Blood pressure is 110/50 mm Hg with a respiratory
rate o 20, and Sat 89% on 6 L/min by nasal cannula. T e
patient is intubated and placed on mechanical ventila-
tion. A secondary survey is per ormed, which reveals no
additional injuries. T e patients weight is 70 kg.
1. T e patient is placed on 100% FiO2. An arterial
blood gas is per ormed with the ollowing results:
pH: 7.24; pCO2: 32 mm Hg; pO2: 460 mm Hg;
HCO3: 16 mEq/L; Base Excess: 12 mEq/L; Lactate:
8 mmol/L. Which o the ollowing is the most
appropriate next step in management?
A. Intravenous methylene blue
B. Hyperbaric oxygen
C. Activated charcoal
D. Hydroxocobalamin
E. Decrease FiO2
2. Following the appropriate intervention in
Question 1, the patient is started on 800 cc/hr o
lactated ringers and trans erred to the intensive
care unit (ICU). A oley catheter is placed and af er
4 hours he is noted to have 20 cc o urine output
or 2 hours. Select the next most appropriate step
in management.
A. Continue lactated ringers (LR) at 800 cc/hr or
8 hours total, then decrease to 400 cc/hr or the
ollowing 16 hours.
B. Increase LR to 1000 cc/hr then monitor urine
output over the next hour.
C. Bolus LR and titrate to a urine output o 30 to
50 cc/hr.
D. Bolus LR and titrate to a urine output o 100 to
200 cc/hr.
3. Af er 4 hours in ICU, the patients right hand
is noted to be cold. You are unable to palpate
a radial or ulnar pulse. His vitals at this point
are: emperature: 97.5; HR: 140/min; BP: 90/40
(mean arterial pressure (MAP): 57) mm Hg; Sat:
100% on assist control/volume control (AC/VC)
mechanical ventilation: FiO2: 60%; RR: 20/min;
tidal volume ( V): 400 cc; positive end-expiratory
pressure (PEEP): 5 mm Hg. Which is the next most
appropriate step in management?
A. Bedside escharotomy o right arm.
B. Immediate trans er to the operating room or
asciotomy.
C. Initiation o vasopressor therapy to target a MAP
o 65 mm Hg.
D. Excision o right arm burns with split thickness
skin gra rom le thigh.
4. Af er ICU admission, topical ma enide acetate
(Sul amylon) is placed on the burn wounds. On
hospital day 3, labs are per ormed and enteral
298 G EN ERAL S U RG ERY EXAM IN ATI O N AN D BO ARD REVIEW
eeding is started. Labs reveal a normal white
blood cell (WBC) count at 10 K/L, normal glucose
at 110 mg/dL, and a chemistry panel remarkable
or a HCO3 o 12 mEq/L. An arterial blood gas
demonstrates pH: 7.22; pCO2: 24 mm Hg; pO2:
200 mm Hg; HCO3:12 mEq/L; Base Excess: 16
mEq/L, and Lactate: 2 mmol/L
Which o the ollowing is the next most appropriate
step in management?
A. Decrease tube eeding rate.
B. Initiate systemic antibiotics.
C. Discontinue any topical antimicrobial treatment.
D. Change topical antimicrobial to silver nitrate.
E. No change in management is indicated.
5. On hospital day 4, the patient is doing well and the
decision is made to per orm excision and graf ing
o his burns. Which o the ollowing statements
about excision and graf ing is true?
A. Excision and gra ing o deep burns should be
delayed at least 2 to 3 weeks to ensure that the
burns have ully demarcated.
B. T e ideal gra or burn excision wounds is a
widely meshed ull thickness skin gra .
C. Split-thickness skin gra sites may be re-used or
additional gra harvesting on a weekly basis.
D. Negative pressure wound therapy (NPW ) has
no place in the management o burn wounds.
E. Human cadaver allogra may be gra ed to a
burn wound to protect it until an appropriate
autogra can be placed i there is not enough
donor skin is available.
ANSWERS
1. D. Smoke inhalation injury is primarily a chemical
injury to the tracheobronchial tree. Most thermal
energy is dissipated in the upper airway. Inhala-
tion injury increases mortality in burns by 20% and
increases pneumonia risk by 40%. Cyanide poisoning
in particular is requently atal and there is no easy
method o diagnosis. Cyanide binds to cytochrome
oxidase and stops cellular respiration. T e diagnosis
is suggested in any enclosed space re where patients
have evidence o smoke inhalation and su er rom
altered mental status, and have a lactic acidosis; it
may present with variable signs or symptoms rom
mild con usion and hyperventilation to complete
obtundation, tachyarrthymia, and cardiac arrest.
Because o the di culty with diagnosis, a high index
o suspicion is necessary and treatment should be
started immediately. Hydroxocobalamin should be
administered to any patient who has su ered smoke
inhalation and demonstrates signs o cardiovascular
instability.
Carbon monoxide poisoning is the leading cause
o death due to unintentional poisoning in the United
States. Carbon monoxide binds to hemoglobin to
make carboxyhemoglobin with an a nity 200 times
higher than oxygen. T e most common symptom o
carbon monoxide poisoning is headache, however,
similar to cyanide poisoning, the symptoms may
be nonspeci c, but severe poisoning leads to coma,
arrhythmias, and death. reatment involves 100%
oxygen at normal atmospheric pressure with a tight-
tting mask (normobaric oxygen) or via ventilator
in the intubated patient. Hyperbaric oxygen (HBO)
may be indicated or severe carbon monoxide
poisoning.
2. B. T e rule o nines is used to calculate the percent-
age body sur ace area (BSA) burned in adults. Only
second and third degree burns are included in the
calculation o total BSA burned; rst degree burns
are not.
T e most commonly used ormula or calculating
crystalloid resuscitation needs in the rst 24 hours is
the Parkland ormula:
First 24 resuscitation = 4 cc tBSA% burn
body weight (kg).
Hal o this f uid is given in the rst 8 hours a er
injury, and hal in the next 16 hours.
It is important to note that the Parkland or-
mula is only a guideline and intravenous f uid
needs should be titrated to urine output o 30 to
50 cc/hr in most adults. I this urine output range
is not achieved, the IV f uid rate should be adjusted
/+ 25% each hour until the desired urine output
is reached. Fluid boluses should be avoided unless
the patient is hypotensive as it could lead to over-
resuscitation.
3. A. Full thickness or deep partial thickness burns
that are circum erential around an extremity or chest
will prevent normal elastic movement o the skin.
Edema a er f uid resuscitation can cause tissue pres-
sure to rise underneath this leathery skin and impair
 C H AP TER 7 8 MA j O R BU RN S AN D S M O k E I N H ALATIO N
circulation. T e treatment is escharotomy, which
involves a ull thickness incision through the burned
skin (epidermis and dermis down to subcutaneous
at). T e incision is made along the medial or lat-
eral aspect o the limb, or, in the chest, in the mid-
axillary line, to decompress underlying structures.
T e incisions should only be through the eschar, as
they should not involve the deeper ascia. Although
escharotomy is o en con used with asciotomy, the
majority o circum erential extremity burns resulting
in signs o elevated compartment pressures require
only an escharotomy, and not a asciotomy.
4. D. T is patient has a severe metabolic acidosis that
is likely due to treatment with Ma enide acetate
(Sul amylon). Ma enide acetate is a weak carbonic
anhydrase inhibitor and can produce a non-gap met-
abolic acidosis. Silver sul adiazine has broad spec-
trum activity and some activity against pseudomonas,
but has poor eschar penetration. Ma enide acetate has
good eschar penetration. Silver nitrate has broad spec-
trum activity and good eschar penetration, but stains
skin and sheets black, and can cause hyponatremia by
leaching sodium rom tissues. Silver nitrate however
is the best alternative topical agent in this situation.
Systemic antibiotics should not be given prophylacti-
cally, only or treatment o proven in ections.
5. E. One o the greatest achievements in burn care was
the adoption o early excision and gra ing o deep
burns. Early excision and gra ing o burn wounds
is associated with decreased mortality and decreased
hospital length o stay.
Ideally, all devitalized tissue should be removed
in the rst week. Excision can be per ormed either
by tangential excision (layers o burned tissue are
excised until a bleeding wound bed is reached) or by
ascial excision (excision to the layer o the ascia).
Fascial excision results in less bleeding but can cause
signi cant cosmetic de ormities.
Skin coverage o excised areas is best done with
meshed split thickness skin gra s but should be
avoided in cosmetically sensitive areas (e.g., the ace).
Meshing allows a larger sur ace area to be covered
as well as allowing space or blood and f uid to leak
through the gra lessening the risk o hematoma or
seroma ormation under the gra . Donor sites may
be recropped a er they have healed, usually around
2 to 3 weeks. I there is a shortage o donor skin, skin
299
substitutes may be used. Cadaver allogra is a good
option or temporary coverage.
BIBLIOGRAPHY
Albright JM, Davis CS, Bird MD, et al. T e acute pulmonary
inf ammatory response to the graded severity o smoke
inhalation injury. Crit Care Med. 2012;40(4):111321.
Asmussen S, Maybauer DM, Fraser JF, et al. Extracorporeal
membrane oxygenation in burn and smoke inhalation
injury. Burns. 2013;39(3):42935.
Barajas-Nava LA, Lpez-Alcalde J, Roqu i Figuls M, Sol I,
Bon ll Cosp X. Antibiotic prophylaxis or preventing
burn wound in ection. Cochrane Database Syst Rev. June
6, 2013;6:CD008738.
Blumetti J, Hunt JL, Arnoldo BD, et al. T e Parkland or-
mula under re: Is the criticism justi ed? J Burn Care Res.
2008;29(1):1806.
Cartotto RC1, Innes M, Musgrave MA, et al. How well does
the Parkland ormula estimate actual f uid resuscitation
volumes? J Burn Care Rehabil. 2002;23(4):25865.
Cortazo JA, Lichtman AD. Methemoglobinemia: A Review
and recommendations or management. J Cardiothorac
Vasc Anesth. August 13, 2013;ii:S10530770(13)000438.
Gibran N. Burns. In: Mulholland MW, Lillemoe KD, Doherty
GM, et al., eds. Greenf elds Surgery Scientif c Principles and
Practice. 5th ed. Philadelphia, PA: Lippincott Williams &
Wilkins; 2011:21436.
Guzman JA. Carbon Monoxide Poisoning. Crit Care Clin.
2012;28(4):53748.
Hettiaratchy S, Papini R. Initial management o a major burn:
II Assessment and resuscitation. BMJ. 2004;329(7457):
1013.
Leversedge F, Moore J, Peterson BC, Seiler JG. Compart-
ment syndrome o the upper extremity. J Hand Surg.
2011;36(3):54459.
Lin JJ, Chung XJ, Yan CY, Lau HL. A meta-analysis o trials
using the intention to treat principle or glutamine sup-
plementation in critically ill patients with burn. Burns.
2013;39(4):56570.
Milner SM, Asuku ME. Burn Wound Management. In: Cam-
eron JL, Cameron AM, eds. Current Surgical T erapy. 11th
ed. Philadelphia, PA: Elsevier Saunders; 2014:112831.
OBrien DJ, Walsh DW, erri CM, Hall AH. Empiric man-
agement o cyanide toxicity associated with smoke inhala-
tion. Prehosp Disaster Med. 2011;26(5):37482.
Ong YS, Samuel M, Song C. Meta-analysis o early excision o
burns. Burns. 2006;32(2):145150.
Orgill DP. Exicision and Skin Gra ing o T ermal Burns.
N Eng J Med. 2009;360(9):893901.
Perel P, Roberts I. Colloids versus crystalloids or f uid resus-
citation in critically ill patients. Cochrane Database Syst
Rev. 2007;(4):CD000567.
Piccolo NS, Piccolo MS, Piccolo PD, et al. Escharotomies,
asciotomies and carpal tunnel release in burn patients
review o the literature and presentation o an algorithm
or surgical decision making. Handchir Mikrochir Plast
Chir. 2007 Jun;39(3):1617.
300 G EN ERAL S U RG ERY EXAM I N ATIO N AN D BO ARD REVI EW

Rousseau AF, Losser MR, Ichai C, Berger MM. ESPEN
endorsed recommendations: Nutritional therapy in major
burns. Clin Nutr. 2013;32(4):497502.
Royall D, Fairholm L, Peters WJ, Jeejeebhoy KN, Allard JP.
Continuous measurement o energy expenditure in ven-
tilated burn patients: an analysis. Crit Care Med. 1994;
22(3):399406.
Shadgan B, Menon M, Sanders D, et al. Current thinking about
acute compartment syndrome o the lower extremity. Can
J Surg. 2010;53(5):32934.
Spodaryk M, Kobylarz K. T e Usability o Harris-Benedict
and Curreri Equations in Nutritional Management o T er-
mal Injuries. Ann Burns Fire Disasters. 2005;18(3):117
121.
 79
Surgical Nutrition

Julia B. Greer

A 49-year-old woman who has medically re ractory C. 30% IV at emulsion

Crohns disease and high ileostomy output (2200 mL/ D. Omega-3 atty acids
day) is re erred to your clinic. She has undergone sev- E. Insulin
eral abdominal surgeries or complications o her
Crohns and she currently has a diverting ileostomy and 3. Af er 8 weeks at home receiving parenteral
approximately 120 cm o her small bowel. O note, she nutrition, your patient develops hair loss, a
has been unable to tolerate any in ammatory bowel dis- pustular rash around her mouth, and darkening o
ease medications aside rom corticosteroids. her skin creases. T e most likely cause is:
T e patient was admitted to an outside hospital twice A. Copper de ciency
in the past 3 months or rehydration and repletion o B. Hyperkalemia
sodium, potassium, and magnesium. She now comes to C. Hyperglycemia
your institution complaining o increased ostomy out- D. Magnesium de ciency
put, lightheadedness, atigue, and nausea. She reports a E. Zinc de ciency
recent weight loss o approximately 20 pounds (approx-
imately 15% o total body weight). A Hickman catheter 4. All individuals who receive total parenteral
is placed in her right subclavian vein and she receives nutrition or >13 weeks will develop:
3 days o parenteral nutrition without complications. A. Venous thrombosis
Insurance coverage or teduglutide is pending and she B. Steatohepatitis
is discharged home on parenteral nutrition. You would C. Gallbladder sludge
like to per orm an ileostomy takedown but would like D. Cholelithiasis
to improve her nutritional status rst. E. Re eeding syndrome

1. Compared to enteral nutrition, parenteral 5. I your patient on parenteral nutrition suddenly

nutrition (PN): spikes a ever, the most important entity to rule
A Is less expensive out is:
B. Does not su er rom product shortages A. A Crohns disease are
C. Preserves immunologic unction o gut B. A catheter line in ection
D. Is not associated with metabolic bone dys unction C. An in ection at the ostomy site
E. Is less likely to cause diarrhea D. Clostridium dif cile colitis
E. A urinary tract in ection
2. Basic parenteral nutrition ormulations include:
A. Sucrose
B. Amino acids
302 G EN ERAL S U RG ERY EXAM IN ATI O N AN D BO ARD REVIEW
ANSWERS
1. E. Compared to enteral nutrition, PN is less likely to
cause diarrhea. Enteral nutrition is delivered directly
to the GI tract and its hyperosmolarity may result in
diarrhea, especially in patients with an underlying
condition that causes malabsorption. Diarrhea has
been shown to occur in as many as 95% o patients
who receive enteral eeds. PN is considerably more
expensive than enteral nutrition. Shortages o many
orms o product, especially vitamin and trace min-
eral components, has been causing delays in initiation
o PN as well as inconsistent mixing and matching
o di erent brands o product, which may result in
certain micronutrient de ciencies i the provider
does not have expertise with PN. Because it com-
pletely bypasses the GI tract, PN does not preserve
the immunologic unction o gut. PN has been asso-
ciated with metabolic bone dys unction and abnor-
mal bone metabolism and some patients have been
shown to develop osteoporosis and osteomalacia.
2. B. Standard components o PN ormulas include
amino acids, dextrose, a 10% or 20% IV at emulsion
to provide essential atty acids, electrolytes (sodium
phosphate, sodium chloride, sodium acetate, potas-
sium phosphate, potassium chloride, potassium
acetate, magnesium sul ate, and calcium gluconate),
multi-component vitamins and multi-component
trace minerals. Some potential additives include
cysteine, regular insulin, and additional trace vita-
mins or elements as required. Although omega-3
atty acid-enriched PN ormulations have been stud-
ied as a potential means o decreasing in ammation
and increasing immune unction in certain subsets
o patients, standard PN ormulations do not contain
them at this time.
3. E. Because copper works with iron to orm red
blood cells, an early sign o copper de ciency is ane-
mia. Low body temperature, osteoporosis, low white
blood cell count, irregular heartbeat, loss o skin pig-
mentation, and thyroid problems may also occur due
to a de ciency o copper. Hyperkalemia is associ-
ated with a slow or irregular heartbeat and weakness.
Signs o hyperglycemia include weakness, nausea,
excessive thirst/urination/appetite, headache, irrita-
bility, and abdominal pain. Severe hyperglycemia can
lead to unconsciousness. A magnesium de ciency
o en mani ests as cardiac and muscle irregularities,
including arrhythmia, weakness, muscle cramps or
spasms, restless leg syndrome, and general agitation;
additional signs and symptoms o low magnesium
include nausea, vomiting, insomnia, and con usion.
A pathognomonic sign o zinc de ciency is hair
loss. Skin lesions, including acne, a perioral pus-
tular and darkening o skin olds, are requently
observed. Loss o appetite, decreased motor skills,
and decreased immunity may characteristic o low
dietary zinc. PN must be ormulated to address de -
ciencies at initiation as well as those that may occur
over the course o hyperalimentation. While elec-
trolyte levels are routinely monitored, one should be
aware o the potential or vitamin and trace mineral
de cits. Individual with high output stula or ostomy
can develop metabolic disturbances. T is patient
may have had a zinc de ciency prior to receiving PN
which should have been addressed and monitored.
4. C. Catheter-related venous thrombosis is a airly rare
complication o PN, occurring in 1% to 3% o indi-
viduals per catheter-year. Deleterious e ects o PN
on the liver and gallbladder are well known to clini-
cians. Hepatic steatosis, which may mani est as atty
liver in ltration, may occur in PN patients within 1
to 2 weeks o initiating PN. It is reversible and can be
managed by limiting the at content. Liver unction
tests (LF s) should be checked weekly or individu-
als on PN and i they are elevated, lipids should be
minimized to < 1 g/kd/day and total or peripheral PN
should be cycled over 12 hours to rest the liver.
I total bilirubin is > 510 mg/dL due to hepatic
dys unction, trace elements should be discontinued
due to the potential or toxicity o manganese and
copper. Cholestasis is inevitable during PN because
there are no intestinal nutrients to stimulate hepatic
bile ow. Cholestasis typically occurs 2 to 6 weeks a er
starting PN and is indicated by progressive increases
in total bilirubin and elevated serum alkaline phos-
phatase. While cholelithiasis is not uncommon dur-
ing PN, it is certainly not ubiquitous. Re- eeding
syndrome is a complication that begins rapidly a er
starting PN in a severely malnourished individual,
typically a person who has been in a starvation state
or > 710 days. T is syndrome is characterized by
a severe shi in uid and serum electrolyte levels,
especially hypophosphatemia, resulting rom intra-
cellular electrolyte movement. Severe systemic com-
plications, and even death, can result rom re- eeding
syndrome. Correcting electrolyte abnormalities
prior to initiating PN is preventative or re- eeding

syndrome. Although the previous complications may
occur or some individuals on PN, all PN patients
will develop gallbladder sludge a er receiving PN or
13 weeks.
5. B. Any o the entities listed in question 5 may cause
your patient to become ebrile but catheter-related
bloodstream in ections (CR-BSI) are the most com-
mon and most serious complication o PN. Adequate
nutrition is a cornerstone or strength preservation
and immune system unction in patients with serious
gastrointestinal illnesses and proper training o am-
ily members and ancillary health personnel or home
PN is essential. Sterile technique when manipulating
the catheter is imperative. Not all patients with a CR-
BSI will present with pyrexia but a sudden increase in
body temperature and an elevated C-reactive protein
provide a high index o suspicion. High white blood
cell count, low albumin, and/or elevated total biliru-
bin may be present. Catheter maintenance or home
parenteral nutrition patients and repeated removal/
reinsertions can result in loss o venous access.
Whenever possible, salvage o an in ected tunneled
catheter, such as the Hickman catheter used in this
patient, should be attempted. T e most e ective way
to prove the existence o a CR-BSI is to simultane-
ously draw blood cultures rom the central catheter
and rom a peripheral source. Other sources o ever
should be investigated.
BIBLIOGRAPHY
Ayers P, Adams S, Boullata J, et al. A.S.P.E.N. Parenteral nutri-
tion sa ety consensus recommendations: ranslation into
practice. Nutr Clin Practice. June 2014;29(3):27782.
Buchman AL, Howard LJ, Guenter P, et al. Micronutrients
in parenteral nutrition: oo little or too much? T e past,
present, and recommendations or the uture. [Erratum
appears in Gastroenterology. April 2010;138(4):1633. Note:
Dosage error in article text.] Gastroenterology. November
2009;137(5 Suppl):S16.
Chang A, Enns R, Saqui O, et al. Line sepsis in home par-
enteral nutrition patients: Are there socioeconomic risk
actors? A Canadian study. JPEN. NovemberDecember
2005;29(6):40812.
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Chang SJ, Huang HH. Diarrhea in enterally ed patients: Blame
the diet? Curr Opin Clin Nutr Metab Care. September
2013;16(5):58894.
Clare A, eubner A, Sha er JL, et al. What in ormation should
lead to a suspicion o catheter sepsis in HPN? Clin Nutr.
August 2008;27(4):5526.
Dibb M, eubner A, T eis V, et al. Review article: the manage-
ment o long-term parenteral nutrition. Aliment Pharm &
T er. March 2013;37(6):587603.
Dimick JB, Swoboda S, alamini MA, et al. Risk o coloniza-
tion o central venous catheters: Catheters or total paren-
teral nutrition versus other catheters. Amer J Crit Care. July
2003;12(4):32835.
Gastmeier P, Weist K, Ruden H. Catheter-associated primary
bloodstream in ections: Epidemiology and preventive
methods. In ection. 1999;27(Suppl 1):S16.
Guenter P, Holcombe B, Mirtallo JM, et al. Parenteral nutri-
tion utilization: Response to drug shortages. JPEN. January
2014;38(1):1112.
Hamilton C, Seidner DL. Metabolic bone disease and
parenteral nutrition. Curr Gastroenterol Rep. August
2004;6(4):33541.
Lee JW. Fluid and electrolyte disturbances in critically ill
patients. E & BP. December 2010;8(2):7281.
Maroulis J, Kal arentzos F. Complications o parenteral
nutrition at the end o the century. Clin Nutr. October
2000;19(5):295304.
McWhirter D. Parenteral nutrition line sepsis: T e dif culty
in diagnosis. Proc Nutr Soc. November 2010;69(4):508510.
Messing B. Gallbladder sludge and lithiasis: Complication o
bowel rest. Nutrition. MarchAprril 1990;6(2):1901.
Messing B, Bories C, Kunstlinger F, Bernier JJ. Does total par-
enteral nutrition induce gallbladder sludge ormation and
lithiasis? Gastroenterology. May 1983;84(5 Pt 1):101219.
Mirtallo JM. Consensus o parenteral nutrition sa ety issues
and recommendations. JPEN. March 2012;36(2 Suppl):62S.
Radrizzani D, Bertolini G, Facchini R, et al. Early enteral
immunonutrition versus parenteral nutrition in critically
ill patients without severe sepsis: A randomized clinical
trial. Intensive Care Med. August 2006;32(8):11918.
Sabiston D. Jr, Lyerly HK. Metabolism in Surgical Patient. In:
Sabiston D. Jr, Lyerly HK, eds. extbook o Surgery: T e Bio-
logical Basis o Modern Surgical Practice. 15th ed., Philadel-
phia, PA: Elsevier Saunders; 1997:13775.
Seres DS, Valcarcel M, Guillaume A. Advantages o enteral
nutrition over parenteral nutrition. T er Adv Gastroenterol.
March 2013;6(2):15767.
Whelan K, Schneider SM. Mechanisms, prevention, and man-
agement o diarrhea in enteral nutrition. Cur Opin Gastro-
enterol. March 2011;27(2):1529.
 80
Blood Products and rans usion
Stephen R. Odom
A 33-year-old emale (G3P2) 31 1/7 weeks pregnant,
with severe vaginal bleeding is taken emergently to the
operating room or cesarean section. Intraoperatively, a
percreta is identi ed with involvement o the bladder
and pelvic wall. A er delivery o the baby, an emergent
hysterectomy is per ormed or massive bleeding. Blood
loss was estimated at 15 liters. T e patient was given
7000 mL o crystalloid, along with 40 units o packed
red blood cells, 10 units o resh rozen plasma, and
20 units o platelets.
1. Which o the ollowing is an indication or blood
trans usion?
A. Serum hemoglobin < 10 g/dL
B. Central venous oxygen concentration < 55%
C. rauma score > 14
D. Loss o 20% o total body blood volume
E. Ongoing bleeding with tachycardia, systolic
blood pressure < 90 mm Hg, oliguria, acidosis,
and/or elevated base de cit
2. Which o the ollowing is true o trans usion-
related acute lung injury (TRALI)?
A. Improvement when well-resuscitated, takes
> 2 weeks.
B. It is caused by anti-HLA-antibodies in blood
products that activates recipient leukocytes.
C. Acute respiratory illness arises within 2 days o
trans usion o blood products.
D. Is easy to di erentiate rom acute respiratory dis-
tress syndrome (ARDS).
E. It is not associated with the number o trans u-
sions or the age o blood.
3. Which o the ollowing non-trans usion strategies
is o proven benef t in reducing blood product
trans usion in stable trauma patients?
A. Minimize blood loss, use o autologous blood
salvage, avoidance o coagulopathy and hypo-
thermia, and damage control techniques
B. Pelvic binders
C. Blood substitutes
D. Factor V concentrate
E. ranexamic acid, i used more than 12 hours
a er the traumatic event
4. Which o the ollowing statements regarding
heparin-induced thrombocytopenia (HIT) is true?
A. HI is an IgA antibody mediated response to
heparin-platelet actor IV complexes.
B. Procine un ractionated heparin (UFH) is more
likely to cause HI than bovine UFH.
C. T e combined sensitivity and speci city o ELISA
and serotonin unctional assay is about 70%.
D. reatment o con rmed HI involves stopping
heparin and initiation o war arin therapy.
E. Patients with remote history o HI can be sa ely
treated with heparin.
5. Which o the ollowing statements regarding
complications o blood trans usion is true?
A. Risk o hepatitis C in ection per unit o packed
red blood cells is 1 in one million.
B. Hyperkalemia is a rare but requently atal disor-
der seen in massive blood trans usion.
C. Citrate can lower serum calcium and magnesium.
 C H AP TER 8 0 Bl o o d P Ro d u C Ts An d TRAn s f u s i o n
D. Massive trans usion requently causes acidosis.
E. ABO incompatible blood trans usion is a rare
cause o hemolytic reaction.
ANSWERS
1. E. Speci c triggers or blood trans usions have
been the subject o a large amount o research, and
the decision to trans use is not always clear. Data
indicate that in a patient without cardiac or lung
disease and hemodynamic stability, a hemoglobin
7 g/dL is satis actory to minimize blood trans u-
sion without adversely a ecting mortality. What is
clear rom these studies is that a liberal trans usion
strategy is not help ul or oxygen delivery but has a
negative e ect on the immune system. In addition,
class o hemorrhage by itsel is not an indication or
trans usion unless systemic hypotension, re ractory
tachycardia, oliguria, lactic acidosis are present with
evidence o ongoing bleeding.
Systemic venous oxygen saturation (SvO2) is an
attractive measure o oxygen consumption, but can-
not be associated with parameters o blood loss or
severity o injury and so, by itsel , cannot represent a
reason to trans use a patient.
T e trauma score is a physiologic score that repre-
sents the sum o scores or respiratory rate and e ort,
capillary re ll, systolic blood pressure, and Glasgow
coma score. In this scoring system, a higher number is
a less severe injury. Recent data suggest that over 90%
o patients with a trauma score > 14 did not need a
blood trans usion. Both the revised trauma score and
the ISS have been shown, interestingly, to predict the
need or trans usion is severe pelvic trauma.
T e only reliable criteria or the need to trans-
use include clinical criteria, like ongoing bleeding,
re ractory tachycardia, decreased systolic blood pres-
sure, oliguria, lactic acidosis, and elevated base de cit.
A single criterion has been elusive.
2. B. RALI is an acute respiratory complication o
blood trans usion that occurs within 4 to 6 hours
o trans usion o product and cannot be traced to
another acute lung injury risk actor. T e syndrome
is very similar to ARDS o other etiologies, and o en
cannot be di erentiated. Overlapping syndromes
include trans usion associated circulatory overload
( ACO). RALI is an anti-HLA-antibody mediated
reaction rom recipient leukocytes. Once comple-
ment is activated, acute lung injury ensues. Other
305
theories, including the roles o non-polar lipids and
activated platelets are less well supported in the lit-
erature. Resolution in a well resuscitated patient nor-
mally occurs within 48 hours. Mortality is around
6% (as compared to much higher mortalities in
ARDS). Risk actors or the development o RALI
include increased number o trans usions, possibly
age o blood trans used, emale plasma donor, and
anti-HLA-antibody complement. Patient risk actors
include higher IL-8 level, shock, liver surgery, cirrho-
sis, positive uid balance, elevated peak airway pres-
sures, and current smoking.
3. A. T ere are multiple non-trans usions options in
surgical patients, many o which have proven bene -
cial in decreasing number o trans usions required.
Initially, care ul surgical technique (minimize blood
loss, avoid hypothermia and coagulopathy, damage
control, etc.) and care ul treatment o preoperative
anemia are clearly associated with decreased need
or trans usion. While pelvic binders are recom-
mended by the American College o Surgeons there
are no clinically relevant data to support their use.
Blood substitutes, including human products, bovine
products, and genetically engineered hemoglobin
are available. O these products, the genetically engi-
neered hemoglobin is promising, in that the cross-
match is avoided (timely administration), osmotic
pressure is increased (resuscitative uid) and blood
pressure is increased (vasopressor activity), but it
remains to be determined that these products are
bene cial in reducing blood trans usions in trau-
matically injured or critically ill patients.
Recombinant actor VII concentrate, not actor V,
enhances thrombin generation and platelet activation
and has been shown to decrease the need or massive
trans usion o the severely injured trauma patients. A
multicenter Phase III trial demonstrated a decrease in
blood product usage, but did not demonstrate a mor-
tality di erence rom placebo. It seems reasonable to
avoid its use in elderly patients (> 75 years old) as they
have increased risk o arterial thrombosis. ranexamic
acid is an anti brinolytic agent that blocks binding o
plasmin to brin. In the CRASH-2 trial, over 20,000
major trauma patients were evaluated. Early use o
tranexamic acid decreased death rate without dem-
onstrated major side e ects. Use a er 3 hours is not
bene cial. ranexamic acid has also been shown to
decrease the size o intracranial bleeding lesions in
trauma patients (CRASH-2 collaborators).
306 G En ERAl s u RG ERY EXAM i n ATi o n An d Bo ARd REVi EW
4. E. HI is an IgG mediated disease directed at
heparin-platelet actor IV (PF-4) complexes. Bovine
UFH increases risk o HI compared to porcine
derived UFH. Orthopedic surgery/injury, cardiac
surgery, especially heart transplant, the use o UFH
as compared to low molecular weight heparin all
increase the risk o HI . Obstetric patients are at very
low risk o developing HI . T e ELISA test or HI
detects antibodies that react with the heparin-P-F-4
epitope while unctional platelet assays (like the ser-
otonin assay) use radiolabeled platelets mixed with
patients serum and heparin.
T e supernatant is then evaluated or radiolabeled
material. Speci city and sensitivity o the ELISA
test is 50% to 70% and 90%, respectively. Speci c-
ity and sensitivity o unctional assays are 95% and
90%, respectively. Used in conjunction, the sensitivity
and speci city or HI approaches 100%. T e results
must be put into clinical context because between
20% to 60% o patients will orm the heparin-PF-4
complexes that can be seen on the EISA test with-
out the clinical syndrome. Once the diagnosis has
been made, all heparin must be stopped. Even a er
stopping heparin, patients are at increased risk or
thrombotic complications or up to 100 days while
the complexes persist, and require treatment with
a direct thrombin inhibitor (only argatroban and
lepirudin are FDA approved). Factor Xa inhibitors
(dancparoid) are options, but not available in the
United States.
Ancrod (pit viper venom), a glycoprotein IIb/IIIa
inhibitor, has been evaluated in HI , and was ound
to be without ef cacy and may increase thrombotic
risk. Vitamin K antagonists are contraindicated in the
acute phase o HI , but have a role in the long-term
management o thrombotic complications. A er
about 100 days ree rom heparin, the heparin-PF-4
complexes have cleared and patients with previous
episodes o HI can be sa ely treated with heparin
provided ELISA testing is negative. T e IgG response
is not amnestic and previous HI does not increase
risk or uture HI .
5. C. ransmission o in ectious diseases by trans u-
sion in the United States is rare. Bacterial in ection
is clinically apparent in 1:80,000 cases. Storage o
platelets at room temperature may increase risk o
bacterial in ection a er in usion o platelets. Current
rates o viral transmission are as ollows (per unit
trans used): Hepatitis A (1:1 million), Hepatitis B
(1:250,000), Hepatitis C (1:150,000), and HIV
(1:2 million). Cytomegalovirus (CMV) is present in
50% o the population, and is transmitted in 5% in
the in ected units. T e rate o transmission o prion
disease is not known, but is presumably very, very low.
Hyperkalemia a er massive trans usion can be seen
in up to 38.5% in trauma patients but is rarely associ-
ated with clinical sequelae. A er trans usion, new red
blood cell counts can take up potassium resulting in
post-trans usion hypokalemia, so electrolytes should
be closely monitored be ore, during, and a er trans-
usion. Citrate (3 g/unit) is used in stored blood, and
can bind calcium in the blood, resulting in hypocal-
cemia a er massive trans usion.
Clinical signs o hypocalcemia include wid-
ened Q interval, decreased ventricular contractil-
ity, hypotension (related to a decrease in peripheral
vascular resistance), muscle tremors and even PEA
arrest. Hypomagnesemia can also be responsible
or prolonged Q seen a er trans usion. T e pH o
stored blood o en decreases to 6.6 to 6.8 because
o increasing CO2. However, the most requent
acid-base problem seen a er massive trans usion is
alkalosis because o the large amount o citrate in
stored blood. Acidosis seen a er massive trans usion
should be concerning or ongoing tissue hypoper-
usion rather than a result o the trans usion itsel .
ABO incompatible trans usion and the resultant
hemolytic reaction is the most common preventable
potentially atal complication o blood trans usion.
T e most common cause is error along the chain o
identi cation o the unit, the patient, or both.
BIBLIOGRAPHY
Aboudara MC, Hurst FP, Abbott KC, Perkins RM. Hyperka-
lemia a er packed red blood cell trans usion in trauma
patients. J rauma. February 2008;64(2 Suppl):S8691.
Bannon MP, ONeill CM, Martin M, Ilstrup DM, Fish NM,
Barrett J. Central venous oxygen saturation, arterial base
de cit, and lactate concentration in trauma patients. Am
Surg. August 1995;61(8):73845.
Baron JF. Blood substitutes. Haemoglobin therapeutics in
clinical practice. Crit Care. 1999;3(5):R99102.
Bo ard KD, Riou B, Warren B, Choong PI, Rizoli S, Rossaint
R, et al. Recombinant actor VIIa as adjunctive therapy or
bleeding control in severely injured trauma patients: wo
parallel randomized, placebo-controlled, double-blind
clinical trials. J rauma. July 2005;59(1):815.
CRASH-2 Collaborators, Intracranial Bleeding Study. E ect
o tranexamic acid in traumatic brain injury: A nested ran-
domised, placebo controlled trial (CRASH-2 Intracranial
Bleeding Study). BMJ. July 1, 2011;343:d3795.
 C H AP TER 8 0 Bl o o d P Ro d u C Ts An d TRAn s f u s i o n
CRASH-2 trial collaborators, Shakur H, Roberts I, Bautista R,
Caballero J, Coats , et al. E ects o tranexamic acid on
death, vascular occlusive events, and blood trans usion in
trauma patients with signi cant haemorrhage (CRASH-2):
A randomised, placebo-controlled trial. Lancet. July 3,
2010;376(9734):2332.
Davenport RD. Pathophysiology o hemolytic trans usion
reactions. Semin Hematol. July 2005;42(3):1658.
Francis JL, Palmer GJ 3rd, Moroose R, Drexler A. Compari-
son o bovine and porcine heparin in heparin antibody
ormation a er cardiac surgery. Ann T orac Surg. January
2003;75(1):1722.
Hauser CJ, Bo ard K, Dutton R, Bernard GR, Croce MA,
Holcomb JB, et al. Results o the CON ROL trial: Ef cacy
and sa ety o recombinant activated Factor VII in the man-
agement o re ractory traumatic hemorrhage. J rauma.
September 2010;69(3):489500.
Hbert PC, Wells G, Blajchman MA, Marshall J, Martin C,
Pagliarello G, et al. A multicenter, randomized, controlled
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Hirsh J, Raschke R. Heparin and low-molecular-weight hepa-
rin: T e seventh ACCP con erence on antithrombotic
and thrombolytic therapy. Chest. September 2004;126(3
Suppl):188S203S.
Lanzarotti S, Weigelt JA. Heparin-induced thrombocytopenia.
Surg Clin North Am. December 2012;92(6):155972.
Levi M, Levy JH, Andersen HF, rulo D. Sa ety o recom-
binant activated actor VII in randomized clinical trials.
N Engl J Med. November 4, 2010;363(19):1791800.
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Looney MR, Gilliss BM, Matthay MA. Pathophysiology o
trans usion-related acute lung injury. Curr Opin Hematol.
September 2010;17(5):41823.
Perkins RM, Aboudara MC, Abbott KC, Holcomb JB. Resuscita-
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Popovsky MA, Moore SB. Diagnostic and pathogenetic con-
siderations in trans usion-related acute lung injury. rans-
fusion. November-December 1985;25(6):5737.
Starr AJ, Grif n DR, Reinert CM, Frawley WH, Walker J,
Whitlock SN, et al. Pelvic ring disruptions: Prediction o
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 81
Necrotizing Fasciitis
Allyson L. Berglund and John M. Giurini
A 33-year-old emale with a 19 year history o type 2
insulin dependent diabetes complicated by peripheral
neuropathy, peripheral vascular disease, and chronic
kidney disease presents to the emergency room com-
plaining o worsening right oot pain and swelling over
the past 3 days. She has a history o Charcot de ormity
to her right oot with a chronic right oot ulceration that
has been treated with weekly debridements and wound
care. She endorses subjective evers and chills.
On examination she has a 1 cm 1 cm 3 cm deep
plantar mid oot ulceration with probing and tracking
noted dorsally to the mid oot. T ere is a strong malo-
dor and her entire oot is signi cantly edematous and
erythematous with signi cant pain on palpation o the
mid oot and lower leg. She has biphasic dopplerable
pulses.
1. Regarding clinical presentation, which of the
following is true?
A. Necrotizing asciitis has the same incidence in
both adult and pediatric populations.
B. Initial signs o necrotizing asciitis include skin
necrosis with a blue or purple discoloration,
crepitus and bullae.
C. T e most constant clinical eature is pain, out o
proportion, to physical ndings.
D. When the borders o in ection appear ill-de ned,
erysipelas diagnosis is more likely than necrotiz-
ing asciitis.
2. With regards to the diagnostic tools that are
available, which of the following is true?
A. Plain radiographs demonstrating subcutaneous
gas is present in about 25% o cases.
B. A computerized tomography (C ) scan has a
sensitivity o about 50%.
C. A laboratory risk indicator or necrotizing asci-
itis (LRINEC) score o 4 indicates an over 50%
chance o necrotizing asciitis.
D. A good physical exam will di erentiate amongst
cellulitis, an abscess and necrotizing asciitis.
3. When necrotizing fasciitis is suspected, immediate
operative debridement is indicated. Which of the
following is true regarding surgical exploration?
A. Surgical exploration should be delayed until vas-
cular status can be evaluated and optimized.
B. In dubious cases, surgical exploration should be
avoided until the diagnosis is con rmed to limit
unnecessary large incisions and tissue debride-
ment.
C. Repeated surgical debridements are not neces-
sary i the patient is on appropriate intravenous
antibiotics.
D. Macroscopic ndings include gray necrotic tis-
sue, dishwater pus, and a positive nger test.
4. Which of the following is true regarding isolated
organisms and antibiotic therapy?
A. Broad spectrum intravenous antibiotics are
enough to stop the spread o in ection.
B. T e most commonly isolated organism is Clos-
tridium, and antibiotic therapy should always
include coverage or this organism.
 C H AP TER 8 1 N EC Ro Ti z i N g FAs C i i Ti s 309

C. Long term intravenous antibiotics or > 4 weeks 2. A. Subcutaneous gas seen on plain radiographs is a
is standard practice when necrotizing asciitis speci c, but not sensitive nding. It has been docu-
has been diagnosed and the patient is ree rom mented that subcutaneous gas on radiographs is ound
systemic symptoms. in as low as 25% o cases, and its absence should not
D. Clindamycin may be use ul in controlling exo- exclude the diagnosis o necrotizing asciitis.
toxin production especially in cases complicated T e diagnosis o necrotizing asciitis can of en be
by streptococcal toxic shock syndrome. delayed and mistaken or cellulitis or abscess. Given
many o the initial signs and symptoms are non-
5. In regards to prognosis, which of the following is speci c, both clinical ndings and laboratory values
true? in addition to advanced imaging i needed should be
A. Patients in ected with Clostridia have lower used in conjunction to help assist in early diagno-
mortality and limb loss rates compared to those sis. In 2004, Wong et al. developed a scoring system
with a polymicrobial or other monocrobial LRINEC, which classi es patients into risk catego-
in ection. ries that determine necrotizing asciitis probability,
B. T e single most important actor that negatively as seen in able 81-1 below. LRINEC scores greater
in uences prognosis is delayed surgical debride- than or equal to 6 have a positive predictive value
ment. (PPV) o 92% and a negative predictive value (NPV)
C. Hyperbaric oxygen therapy (HBO) has been o 96% or necrotizing asciitis.
shown to dramatically decrease limb loss. Magnetic resonance imaging (MRI) has been
D. Diabetes, even in those presenting in diabetic documented to be the most use ul imaging tech-
ketoacidosis, does not have higher mortality or nique when di erentiating necrotizing rom non-
longer hospital stays. necrotizing in ections. Speci c ndings on an MRI
include thickening o the sof tissue and a hyperin-
tense signal on -2 weighted images at the level o
the deep ascia and muscle. C imaging has been
ANSWERS
reported to be more sensitive than plain radiographs,
1. C. Pain, out o proportion to physical ndings, has
been well documented as a constant recurring ea-
ture o necrotizing asciitis. When present, necrotiz- Table 81-1 LABORATORY RISK INDICATORS FOR
NECROTIZING FASCIITIS (LRINEC) SCORE
ing asciitis should always be considered in the
di erential diagnosis. Keys that lead to diagnosis Variable, Units Score
include pain out o proportion to the degree o der- C-Reactive Protein, mg/L
mal involvement as well as severe pain that appears < 150 0 0
to extend beyond the apparent borders o in ection. 150 3.5 4
Necrotizing asciitis is more common in the adult otal white cell count, per mm 2
population, with a reported incidence o 0.40 cases < 15 0 0
per 100,000 as compared to 0.08 per 100,000 pediat- 1525 0.5 1
ric cases per year. While skin necrosis with a blue or > 25 2.1 2
purple discoloration, crepitus and bullae are perhaps Hemoglobin, g/dL
> 135 0 0
the more well recognized signs and symptoms o
11135 0.6 1
necrotizing asciitis, these are late eatures o the dis- < 11 1.8 2
ease, not initial presenting symptoms. Initial present- Sodium, mmol/L
ing signs are of en less speci c and include erythema, 135 0 0
warmth, myalgia, edema, and pain out o portion. As > 141 1.8 2
such, this of en can lead to delayed diagnosis and Creatinine, mol/L
delayed surgical debridement. Erysipelas is di erent 141 0 0
rom necrotizing asciitis in that erysipelas involves > 141 1.8 2
in ection o the super cial layers o the skin and Glucose, mmol/L
10 0 0
cutaneous lymphatics, leading to a well-demarcated
> 10 1.2 1
and of en raised border.
310 g EN ERAL s U Rg ERY EXAM i N ATi o N AN D Bo ARD REVi EW
with the ability to identi y abscesses and other
in ammatory changes, with up to 80% sensitivity.
3. D. Gross intraoperative ndings include thin, watery
gray necrotic uid of en described as dishwater pus,
a oul smelling odor, and necrotic muscle which ails
to respond to electrocautery. A positive nger test is
also characteristic, in which there is ease o dissect-
ing the subcutaneous layer o o the deep ascia with
the surgeons ngers.
Surgical debridement should never be delayed or
optimization o vascular per usion, nor until there
is a de nitive diagnosis as delay in surgical manage-
ment has been shown to be both limb and li e threat-
ening. A delay in surgical debridement more than
24 hours has been shown to be an independent risk
actor or mortality. Furthermore, repeated surgical
debridement may be necessary in order to remove
all necrotic tissue, lessen the bacterial load, expose
the tissues to oxygen to aid in reduction o anaerobic
bacteria, all helping to acilitate more rapid recovery.
4. D. Clindamycin is a protein synthesis inhibitor that
inhibits M protein and exotoxin production. As such,
administration o clindamycin has been shown to be
especially use ul in cases with severe in ammatory
responses, which include cases complicated by strep-
tococcal toxic shock syndrome. Initial management
o suspected necrotizing asciitis cases include broad
spectrum IV antibiotics. Duration o IV antibiotics
af er the source has been controlled and the patient is
ree o systemic signs o in ammation and in ection,
is typically 14 days.
It should be noted that IV antibiotics alone are
not enough to control in ection. Using only IV
antibiotics, mortality approaches 100% because the
antibiotics may not reach the a ected area due to
the thrombosis o vessels. As a result o improved
sanitation, Clostridium species are now a rare cause
o necrotizing asciitis. Rather, Streptrococcus is
the number one isolated organism, ollowed by the
staphylococcus species.
5. B. HBO therapy has been considered as an adjunct
therapy in the treatment o necrotizing asciitis. T is
is based on the theory that necrotizing in ections
are associated with decreased oxygen tension and
ischemia. As such, it is believed that HBO treatment
can reverse these e ects by increasing oxygen ten-
sion and helping to deliver antibiotic therapy across
the bacterial cell wall. However, various studies have
ailed to show any bene ts, including mortality or
hospital stay, with the addition o HBO treatment.
As previously mentioned, delay in surgical
debridement is the single most important actor
with regards to a negative prognosis; a delay o over
24 hours is an independent predictor o mortality. It
is well known that diabetes in itsel is a risk actor
or necrotizing asciitis. T ose with a history o type
2 diabetes and who present in diabetic ketoacido-
sis have been shown to have longer rates o hospital
stays and higher rates o mortality. T is is likely due
to poor glycemic control which contributes to the
pathogenesis and has been correlated to the extent
o disease and poor outcomes. Similarly, in a large
retrospective cohort study, patients with isolated
Clostridium in ections have been shown to have
increased mortality rates, up to our times that when
compared to other monocrobial or polymicrobial
in ections.
BIBLIOGRAPHY
Anaya DA, McMahon K, Nathens AB, et al. Predictors o mor-
tality and limb loss in necrotizing sof tissue in ections.
Arch Surg. 2005;140:1517.
Andreasen J, Green SD, Childers BJ. Massive in ectious
sof -tissue injury: Diagnosis and management o necrotiz-
ing asciitis and purpura ulminans. Plast Recontstr Surg.
2001;107:102535.
Bisno AL, Stevens DL. Streptococcal In ections o Skin and
Sof issues. N Engl J Med. 1996;334(4):2406.
Brown DR, Davis NL, Lepawsky M, Cunningham J, and
Kortbeek J. A multicenter review o the treatment o major
truncal necrotizing in ections with and without hyperbaric
oxygen therapy. Am J Surg. 1994;167(5):485489.
Childers BJ, Potyondy LD, Nachreiner R, et al. Necrotizing
asciitis: A ourteen-year retrospective study o 163 con-
secutive patients. Am Surg. 2002;68:10916.
Edlich RF, Cross CL, Dahlstrom JJ, Long WB III. Modern con-
cepts o the diagnosis and treatment o necrotizing asci-
itis. J Emerg Med. 2010;89:736.
Fustes-Morales A, Gutierrez-Castrellon P, Duran-McKinster
C, et al. Necrotizing asciitis: Report o 390 pediatric cases.
Arch Dermatol. 2002;138:8939.
Hassan Z, Mullins RF, Friedman BC, et al. reating necrotiz-
ing asciitis with or without hyperbaric oxygen therapy.
Undersea Hyperb Med. 2010;37:11523.
Lancerotto L, occo I, Salmaso R, Vindigni V, and Bassetto F.
Necrotizing asciitis: Classi cation, diagnosis and manage-
ment. J Trauma. 2011;72(3):5606.
Lim YJ, Yong FC, Wong CH, and an ABH. Necrotizing as-
ciitis and traditional medical therapy a dangerous liai-
son. Annals of the Academy of Medicine Singapore. 2006;
35(4):2703.

Oncul O, Erenoglu C, op C, et al. Necrotizing asciitis: a
li e threatening clinical disorder in uncontrolled type 2
diabetic patients. Diabetes Research and Clinical Practice.
2008;80(2):21823.
Ozalay M, Ozkoc G, Akpinar S, Hersekli MA, andogan RN.
Necrotizing sof -tissue in ection o a limb: Clinical pre-
sentation and actors related to mortality. Foot Ank Int.
2006;27(8):598605.
Shupak AO, Shoshani I, Goldenber A, et al. Necrotizing asci-
itis: an indication or hyperbaric oxygen therapy? Surgery.
1995;118(5):8738.
Vijayakumar A, Pullagura R, T immappa D. Necrotizing as-
ciitis: Diagnostic challenges and current practices. ISRN
Infectious Diseases. 2014; Article ID 208072.
C H AP TER 8 1 N EC Ro Ti z i N g FAs C i i Ti s 311
Wang YS, Wong CH, ay YK. Staging o necrotizing asciitis
based on the evolving cutaneous eatures. Int J Dermatol.
2007;46:103641.
Wong CH, Khin LW, Heng KS, an KC, and Low CO. he
LRINEC (laboratory risk indicator or necrotizing
asciitis) score: A tool or distinguishing necrotizing
rom other so t tissue in ections. Crit Care Med. 2004;32:
153541.
Wong CH, Chang HC, Pasupathy S, et al. Necrotizing asciitis:
Clinical presentation, microbiology, and determinates o
mortality. J Bone Joint Surg Am. 2003;85:145460.
Wysoki MG, Santora A, Shah RM, and Friedman AC. Nec-
rotizing asciitis: C characteristics. Radiology. 1997;
2003:85963.
 82
Genitourinary rauma
Peter L. Steinberg
A 35-year-old man presents to the emergency depart-
ment as a trauma alert, a er alling 40 eet rom a sca -
old. On primary survey he has no li e threatening
injuries. His vital signs are stable, with a heart rate o 85,
blood pressure o 126/84, and a room air oxygen satura-
tion o 99%.
On secondary survey he is noted to have blood at the
urethral meatus. In addition, he has bruising over the
le ank. He has pain over the pubic symphysis, but his
pelvis is grossly stable. His abdomen is mildly distended.
His rectal examination reveals no blood, normal rectal
tone, and a normal prostate exam. He has not voided
since the incident.
1. What is the next step in diagnosis and management
o blood at the urethral meatus?
A. Passage o a coudee tipped Foley catheter
B. Passage o a three-way Foley catheter
C. Placement o a suprapubic catheter
D. Retrograde urethrography
E. Voiding cystourethrogram
2. Af er concluding his urethra is uninjured, a Foley
catheter is placed and grossly bloody urine is
obtained. Which imaging test is most appropriate in
evaluating his other possible genitourinary injuries?
A. Fluoroscopic cystogram
B. FAS ( ocused assessment with sonography or
trauma) scan
C. Computerized tomography (C ) scan o the
abdomen and pelvis with IV contrast and C
cystogram
D. C cystogram
E. C scan o the abdomen with and without IV
contrast
3. What is the appropriate management o a simple
extraperitoneal bladder rupture?
A. Suprapubic tube placement or 7 days
B. Large bore Foley catheter placement or 10 to
14 days
C. Open exploration and cystorraphy
D. Laparoscopic exploration and cystorraphy
E. Bilateral percutaneous nephrostomy tube place-
ment
4. C scan o the abdomen and pelvis with IV
contrast is indicated to rule out a renal injury in
which clinical scenario(s)?
A. Blunt trauma with gross hematuria
B. Blunt trauma with microscopic hematuria and
normal blood pressure
C. Blunt trauma with microscopic hematuria and
shock (SBP < 90)
D. High energy mechanism o injury
E. A, C, and D
5. T is patient has a Grade 3 lef renal injury and is
hemodynamically stable. What is the appropriate
initial management o that injury?
A. Open renal exploration
B. Renal angiography
C. Serial examination, serial vital signs, and serial
CBC monitoring
D. Ureteral stent placement
E. Nephrectomy

ANSWERS
1. D. Retrograde urethrography is essential in any case
o blood at the urethral meatus, as blood at the mea-
tus may be a sign o a urethral disruption or lacera-
tion. Passage o a Foley catheter blindly in the setting
o a urethral injury may exacerbate a laceration or
lead to placement o the catheter outside o the blad-
der. I the retrograde urethrogram shows the urethra
is intact, then Foley placement can be attempted.
2. C. T is patient is at risk or both bladder and renal
injury, so imaging will be required to assess those
organs. T e bladder is best imaged with either a ret-
rograde gravity cystogram or a C cystogram. T e
kidneys are best imaged with a contrast enhanced C
scan o the abdomen and pelvis, as well as with delayed
images o the ureters to assess or ureteral injury.
A gravity cystogram can also be done with a c-arm
in the operating room i the patient needs operative
intervention. It is critical that gravity cystography
involve oblique views as well as a post drainage f lm,
to assess or leakage posterior to the bladder. Also,
the patient should be f lled via gravity to a volume
o at least 300 to 400 mL, to adequately distend the
bladder. Awake patients should be f lled to a sense o
bladder ullness.
Roughly 90% o all patients with a bladder injury
in a blunt trauma setting will have both gross hema-
turia and a pelvic racture. Additionally, nearly 30% o
patients with gross hematuria and a pelvic racture will
have a bladder injury, so imaging the bladder is essen-
tial in those patients. A minority o patients with a
bladder injury will have only hematuria or only an iso-
lated pelvic racture, so the decision to image the blad-
der in those situations is based on clinical judgment.
Certainly any signs or symptoms o bladder per ora-
tion, such as low urine output, abdominal distension,
or acute kidney injury would warrant cystography.
T e indications or renal imaging in blunt trauma
patients include gross hematuria, microscopic hema-
turia (3 to 5 RBCs per high powered f eld on urinaly-
sis) with systolic BP < 90 mm Hg, and a mechanism
with high energy that could lead to renal injury. A
contrast enhanced C scan with delayed images o
the ureters is the best imaging test in a trauma set-
ting. In the event o urgent exploration, a 1 shot
intravenous pyelogram (IVP) can be per ormed with
2 cc/kg o IV contrast and a single plain abdomi-
nal f lm 10 minutes later, to assess or the presence
C H AP TER 8 2 G En i To u Ri n ARy TRAu m A 313
o two kidneys and to provide a pyelogram o each
renal unit.
3. B. A simple extraperitoneal bladder injury can be
readily managed with Foley catheter drainage alone.
T e catheter must be large enough to allow the egress
o clots and be unlikely to occlude. Most clinicians
would allow 2 weeks o drainage or healing to occur
and would per orm a cystogram prior to catheter
removal.
Operative management is only needed i the
patient is otherwise being explored or i there are
mitigating actors that will preclude healing, such as
ragments o the bone in the bladder injury. In addi-
tion, i there are lacerations to the rectum, vagina,
or the bladder injury involves the bladder neck, oper-
ative repair is best per ormed to prevent a f stula and
allow appropriate healing.
4. E. T e guidelines or renal imaging in blunt trauma
are very well established. In the absence o gross
hematuria, with an insignif cant mechanism o injury,
and without a systolic blood pressure < 90 mm Hg
and microscopic hematuria (> 35 RBCs per HPF),
there is a 99.7% chance the patient does not have a
signif cant renal injury. A contrast enhanced C with
delayed images is the optimal imaging test in this
setting.
5. C. Most renal injuries can be managed with non-
operative intervention. Operative intervention,
including open exploration with repair o a renal
injury or nephrectomy, ureteral stent or percutaneous
nephrostomy placement or urinary extravasation, or
angiography, is required or patients with hemody-
namic instability or or urinary leaks that do not heal
or are complicated by issues such as in ection.
T e majority o renal injuries, especially grade
1 to 3 injuries can be managed without surgical
intervention.
BIBLIOGRAPHY
Broghammer JA, Fisher MB, Santucci RA. Conservative
management o renal trauma: a review. Urology. October
2007;70(4):6239.
Miller KS, McAninch JW. Radiographic assessment o renal
trauma: Our 15-year experience. J Urol. 1995;154:3525.
Morey AF, Brandes S, Dugi DD III, Armstrong JH, Breyer BN,
et al. Urotrauma: AUA Guideline. J Urol, 2014;116.
Wessells H, Suh D, Porter JR, et al.: Renal injury and operative
management in the United States: Results o a population-
based study. J Trauma. 2003;54:423.
 83
Foley rauma
Katherine Carlisle
A 64-year-old male with a history o spinal cord injury,
hypertension, DM2, and tobacco abuse is scheduled to
undergo a video-assisted thoracoscopic surgery (VA S)
or resection o a suspicious lung mass. He voids using
clean intermittent catheterization (CIC) and has been
doing so or the past 8 years. Prior to the start o the
case, the nurse attempts to insert a Foley catheter. She
meets resistance while advancing the catheter and does
not get return o urine.
1. Which of the following is true?
A. A history o prolonged CIC does not increase the
risk o Foley trauma.
B. Voiding symptoms help identi y patients who
are more likely to have di cult catheter place-
ment.
C. T e incidence o urethral stricture as a compli-
cation o chronic catheterization decreases with
duration.
D. Women experience similar rates o urethral
stricture as men.
2. Which of the following is true?
A. In patients with known stricture disease, catheter
placement requires direct visualization.
B. Using CIC to void rather than an indwelling
catheter does not increase risk o alse passage.
C. Indwelling catheters have a lower risk o devel-
oping a urethral stricture.
D. Resistance or obstruction encountered less than
16 cm rom the meatus may suggest urethral
stricture or other anterior urethral pathology.
3. T e next best step for the nurse would be to:
A. Slowly orce the catheter past the resistance.
B. Dilate a possible stricture by slowly in ating the
catheter balloon.
C. Assume the positioning is correct and in ate the
catheter balloon.
D. Remove the catheter.
4. T e nurse repeatedly tries to force the catheter
without success before removing the catheter. T e
urology team is called for consultation. Which of
the following is the next best step?
A. Attempt to blindly dilate the urethra.
B. Per orm cystoscopy.
C. Attempt to pass a larger size catheter.
D. Per orm a retrograde urethrogram.
ANSWERS
1. B. Urethral catheterization is not a benign procedure
and can result in numerous complications to include
hematuria, urinary tract in ection, and urethral stric-
ture, per oration, or erosion. T e incidence o ure-
thral stricture in women is signi cantly less than that
in men and is primarily related to the shorter length
o the urethra, 3.5 to 4 cm in women, versus 18 to
20 cm in men. It is important to do a thorough his-
tory and physical to identi y patients at risk or di -
cult catheter placement. Urologic procedural history
should be reviewed along with any documentation
o prior di cult catheter placement. In men, voiding
symptoms such as decreased or intermittent urinary

stream, valsava to initiate urination, and nocturia
may indicate obstructive pathology such as benign
prostatic hypertrophy. History o repeated urethral
manipulation with CIC or indwelling catheter such
as the patient in our scenario should prompt suspi-
cion or prior urethral trauma and possible di cult
Foley placement.
Incidence o urethral injury and chronic com-
plications increases with prolonged duration o
CIC. Alternate catheter types can provide advan-
tages over straight-tipped catheters such as Foleys
catheter. For example, a Coud catheter which has
a curved tip assists in traversing the prostatic ure-
thra in gentlemen with benign prostatic hyperplasia
(BPH) whereas a Councill open-tipped catheter can
be placed over a guidewire in patients with urethral
stricture.
2. B. Considering the patients known history o pro-
longed CIC, urethral stricture would be high on
the di erential or the etiology o the encountered
resistance during the nurses attempt at Foley place-
ment. Studies comparing long term CIC use versus
indwelling catheter or urinary drainage reveals an
increased risk or development o urethral stricture
in patients with an indwelling catheter, but interest-
ingly no signi cant di erence in the risk or alse
passage between the two groups. T e rst 16 cm
o the urethra is the anterior portion and would
be the most likely location or urethral stricture
related to Foley trauma. T e remaining 2 to 4 cm
corresponds to the posterior urethra and resistance
at this distance may re ect BPH. Had the patient
been previously diagnosed with urethral stricture
or i the providers suspicion or stricture was high,
they may choose to use a smaller silicone catheter
to more easily traverse the narrowed segment with-
out direct visualization. T is technique would be
most e ective in the hands o a urologist or other
provider well trained in urinary tract pathology and
anatomy.
C H AP TER 8 3 F o l Ey TRAu m A 315
3. D. T e most appropriate course o action would be
to remove the catheter. Con rmation o appropriate
catheter placement requires ow o urine and the bal-
loon should not be in ated until this time. Continu-
ing to advance the catheter af er meeting resistance
could result in creation o a alse passage. You should
never in ate the balloon intentionally within the ure-
thra. I a stricture is identi ed it may require dilation
by a urologist with urethral sounds or dilators.
4. B. T e sa est option would be to examine the urethral
anatomy using cystoscopy. T is acilitates placement
o a guidewire beyond any identi ed stricture over
which a catheter can be placed or dilation o a stric-
ture under direct vision. Attempting to pass a larger
catheter in a patient who is suspected to have a stric-
ture would likely result in urther trauma. A smaller
bore catheter would be the appropriate choice. Retro-
grade urethrogram is a contrasted X-ray study to
evaluate the urethra that is of en ordered when ure-
thral trauma is suspected. Although this study could
show evidence o urethral stricture, it would not be
the best choice while in the operating room. T is
study may be obtained as a ollow up study to urther
assess the anatomy o the urethra particularly i surgi-
cal intervention is planned to treat urethral stricture.
BIBLIOGRAPHY
Mndez-Probst CE, Razvi H, Denstedt JD. Fundamen-
tals o Instrumentation and Urinary ract Drainage. In:
Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA,
eds. Campbell-Walsh Urology. 10th ed. Philadelphia, PA:
Elsevier Saunders; 2011:17782.
Perrouin-Verbe B, Labat J, Richard I, et al. Clean intermittent
catheterisation rom the acute period in spinal cord injury
patients. Long term evaluation o urethral and genital tol-
erance. Paraplegia. 1995;33:61924.
Singh R., Rohilla RK, Sangwan K, et al. Bladder management
methods and urological complications in spinal cord injury
patients. Indian Journal of Orthopaedics. 2011;45:1417.
Villanueva C, Hemstreet III GP. Di cult male urethral cath-
eterization: A review o di erent approaches. International
Brazilian Journal of Urology. 2008;34:40112.
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 SECTION 2

Surgical Subspecialties
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Tr a nspl a nt at io n Sur ger y
Ronald A. Gagliano, Jr.
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ransplant SurgeryKidney
J S k
A 61-year-old patient with insulin dependent diabetes
mellitus and end-stage renal disease on hemodialy-
sis presents or evaluation or kidney transplantation.
A suitable cadaveric donor is ound, and the patient
undergoes transplantation at another hospital; the
immediate post-operative course is uncomplicated. en
days later, the patient presents to your hospital and is
noted to have an abrupt decrease in urine output with a
creatinine elevation to 1.5 mg/dL, and has gra tender-
ness on exam. A ever o 100.9F is noted.
1. Wh ch f h f w b h strongly associated with the development o this
m m f h d v
mc ? immunosuppressive therapy.
A. Renal biopsy should rst be per ormed to di er-
entiate between acute rejection and acute inter-
stitial nephritis.
B. Doppler ultrasound should be per ormed to
evaluate vessel patency and rule out ureteral
obstruction.
C. T e dose o cyclosporine should be increased to
treat possible acute rejection.
D. Angiography is indicated to evaluate the vascu-
lar supply to the gra .
E. T e patient should be promptly taken back to
the operating room or re-exploration in order
to salvage the gra .
Cyclosporine levels are drawn on the previous
patient and ound to be at therapeutic levels. A Dop-
pler ultrasound is obtained and shows patent arterial
and vascular f ow with no perinephric f uid collec-
tion. Subsequently, a percutaneous biopsy o the gra
84
shows lymphocytes within the renal tubules and
vascular endothelium. Immunophenotyping o the
biopsy demonstrates -cell preponderance.
2. Wh ch f h f w d h
- v c m c x c d b h
?
A. T is complication is mediated by anti-HLA anti-
bodies and is likely related to a clerical error dur-
ing the pre-transplant cross-match.
B. T e presence o Epstein-Barr virus (EBV) is
d neoplasia, and treatment involves decreasing
C. Failure to treat this condition will increase the
risk o gra loss. Management consists o pulse
corticosteroids and changing maintenance ther-
apy rom cyclosporine to tacrolimus.
D. Risk actors or this complication include peri-
operative hypovolemia, ischemia-reper usion
injury, and the use o an extended-criteria donor.
E. T is viral in ection was likely transmitted via
leukocytes within the donor; treatment includes
ganciclovir and IntraVenous ImmunoGlobulin
(IVIG).
3. Wh ch f h f w c c d -
ch c c m c ?
A. T rombosis o the transplanted renal artery
in the early post-operative period should be
urgently treated with heparin in usion and
angioplasty.
322 G EN ERAL S U RG ERY EXAM IN ATI O N AN D BO ARD REVIEW
B. Renal vein thrombosis may mani est with hema-
turia in the rst week ollowing transplantation.
C. On Doppler ultrasound, identi cation o a
round, sonolucent, septated mass medial to the
renal allogra with associated ureteral compres-
sion is most consistent with a urine leak.
D. Initial management o a lymphocele involves
intra-peritoneal marsupialization (i.e., creation
o peritoneal window).
E. Presence o multiple strictures in the transplanted
ureter during the early post-operative period is
associated with polyoma BK viral in ection.
4. R d h m ch m d f v
mm v , wh ch f h f w diagnosis. I no blood f ow is seen to the transplanted
c c?
A. Cyclosporin binds cyclophilin protein and
blocks IL-2 production.
B. Azathioprine binds antigens on cells, causing
altered cell unction as well as cell depletion.
C. Rituximab binds to FK binding protein, and is
used in maintenance immunosuppression.
D. Sirolimus inhibits the unction o NF-B, dimin-
ishing the response to cytokines.
E. A GAM binds to CD20, leading to initial cyto-
kine release ollowed by B cell depletion.
5. W h d c m c f m
d mm , wh ch f h
f w c c?
A. T e most common malignancy associated with
post-transplantation immunosuppression is
lymphoma.
B. Mycophenolate mo etil and azathioprine are
associated with diarrhea and leukopenia.
C. Antithymocyte globulin is associated with gingi-
val hyperplasia and hirsutism.
D. Post-transplant activation o cytomegalovirus
(CMV) occurs most commonly in patients who
tested seropositive or CMV IgG preoperatively.
E. acrolimus and sirolimus are associated with
nephrotoxicity and post-transplant diabetes.
ANSWERS
1. B. Post-transplant oliguria with elevated creatinine
has multiple possible etiologies to include hypov-
olemia, urinary catheter occlusion, calcineurin inhib-
itor toxicity, viral in ection, delayed gra unction,
hyperacute or acute rejection, renal artery throm-
bosis, renal vein thrombosis, urine leak, or ureteral
obstruction (e.g., by stricture or lymphocele). T e
most requent cause o an elevated creatinine level
post-transplant is calcineurin inhibitor toxicity. A er
this is ruled out, the next step is to evaluate blood
f ow and rule out structural problems with Doppler
ultrasound. I the ultrasound is normal, it is then
appropriate to per orm a renal biopsy, which can di -
erentiate rejection, post-transplant lymphoproli er-
ative disorder (P LD), acute tubular necrosis (A N),
among other diagnoses. I arterial/venous thrombo-
sis, arterial stenosis, or aneurysm is seen on the ultra-
sound, angiography is then indicated to con rm the
kidney on ultrasound or a nuclear medicine renal
scan, then re-exploration is indicated.
2. C. -lymphocytes within the renal tubules and vas-
cular endothelium are characteristic o acute cell-
mediated rejection. Each rejection episode decreases
the long-term unction o the gra , and should be
treated with pulse corticosteroids. Also, i the epi-
sode o rejection occurred on therapeutic calcineu-
rin inhibitor levels, the maintenance therapy should
be changed. In contrast, hyperacute rejection occurs
within minutes to hours o reper usion, mani ests
with rapid mottling and o en gra rupture, and is
mediated by pre- ormed anti-HLA antibodies due
to ABO incompatibility. Hyperacute rejection is rare
due to pre-transplant cross-matching, and is usually
due to clerical error. Post-transplant lymphoproli -
erative disorder (P LD) is associated with EBV, and
can be di erentiated rom acute rejection on biopsy
by the preponderance o B lymphocytes; treatment
is to decrease immunosuppression. Acute tubular
necrosis (A N) may cause oliguria and elevated
creatinine, and risk actors include hypovolemia,
reper usion injury, and use o an extended-criteria
donor. Biopsy would show injury o tubular cells and
casts within the tubule lumen. CMV in ection may
be transmitted within donor leukocytes and also can
cause oliguria with creatinine elevation; treatment is
with ganciclovir. On biopsy, intranuclear or cytoplas-
mic inclusions are characteristic o viral in ections
including CMV.
3. B. Renal artery thrombosis is a rare complication
occurring in 1% o cases, and necessitates return to
the operating room or urgent exploration. New onset

hematuria may be the rst sign o a renal vein throm-
bosis. Lymphoceles are the result o intra-operative
lymphatic disruption and are identi able on ultra-
sound as a round, multi-septated mass medial to the
gra that may compress the ureter. It is di erentiated
rom urine leak sonographically in that a urine leak
would be a non-septated f uid collection in the pel-
vis. Lymphocele is initially managed with percutane-
ous drainage; creation o a peritoneal window can be
help ul or drainage i percutaneous drainage does
not resolve symptoms. Presence o multiple ureteral
strictures in the late post-operative period may be
due to polyoma BK virus, but early ureteral stenosis
is usually due to ischemia or extrinsic compression.
4. A. Cyclosporine is a calcineurin inhibitor which
unctions by binding cyclophilin protein and block-
ing IL-2 production. Azathioprine unctions by
converting 6-mercaptopurine to 6-thioinosine-
5-monophosphate, which inter eres with DNA
and purine synthesis; -cell antigens are bound
and blocked by antilymphocyte globulins such as
A GAM, as well as OK -3 and several monoclonal
antibodies (e.g., basiliximab, dacluzimab). Rituximab
binds to CD20 on B cells, causing depletion; tacroli-
mus and sirolimus (a.k.a. rapamycin) both bind FK
binding protein. Corticosteroids bind a nuclear recep-
tor, inhibiting NF-B and blocking -cell activation.
5. B. Immunosuppression is associated with both
drug-speci c toxicity as well as susceptibility to in ec-
tions and malignancy. T e most common malignancy
associated with post-transplant immunosuppression
is skin cancer, speci cally squamous cell carcinoma.
Post-transplant activation o CMV actually occurs
C H AP TER 8 4 TRAN S P LAN T S U RG ERY KI D N EY 323
most commonly in patients who tested sero-negative
or CMV pre-operatively and received a gra rom
a CMV-seropositive donor. Mycophenolate mo etil
and azathioprine are both antiproli erative agents
with associated GI toxicity and leukopenia. Antithy-
mocyte globulin is associated with cytokine release
syndrome, leukopenia, and serum sickness; gingival
hyperplasia and hirsutism are both associated with
cyclosporine. Like cyclosporine, tacrolimus is a cal-
cineurin inhibitor associated with nephrotoxicity, but
sirolimus is not, and tacrolimus is more strongly asso-
ciated with post-transplant diabetes than sirolimus.
BIBLIOGRAPHY
Adams AB, Kirk AD, Larsen CP. ransplantation immunobi-
ology and immunosuppression. In: ownsend CM, Beau-
champ D, Evers BM, Mattox KL, eds. Sabiston extbook o
Surgery: T e Biological Basis o Modern Surgical Practice.
19th ed. Philadelphia, PA: Elsevier; 2012:61754.
Becker Y. Kidney and Pancreas ransplantation. In: ownsend
CM, Beauchamp D, Evers BM, Mattox KL, eds. Sabiston
extbook o Surgery: T e Biological Basis o Modern Surgical
Practice. 19th ed. Philadelphia, PA: Elsevier; 2012:66681.
Freise C, Stock P. Renal ransplantation. In: Mulholland MW,
Lillemoe KD, Doherty GM et al., eds., Greenf elds Surgery:
Scientif c Principles and Practice. 5th ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2011:53141.
Racusen LC, Solez K, Colvin RB, et al. T e Ban 97 working
classi cation o renal allogra pathology. Kidney Interna-
tional. 1999;55:71323.
Veale JL, Singer JS, Gritsch HA. T e transplant operation and
its surgical complications. In: Danovitch GM. Handbook o
Kidney ransplantation. 5th ed. Philadelphia, PA: Lippin-
cott Williams & Wilkins; 2009:18197.
Wilkinson A. T e First Quarter: T e First T ree Months
A er ransplantation. In: Danovitch GM. Handbook o
Kidney ransplantation. 5th ed. Philadelphia, PA: Lippin-
cott Williams & Wilkins: 2009:198216.
 85
ransplant SurgeryLiver
Joy Sarkar
A 52-year-old patient with a long history o hepatitis C
(HCV) presents with vague epigastric pain and reports
weight loss o 10 pounds over the past 4 months with a
serum AFP level o 600 mcg/L. Contrast computerized
tomography (C ) scan o the liver shows multiple nod-
ules in the hepatic parenchyma.
1. Which of the following is true regarding
liver transplantation in a patient with chronic
hepatitis C?
A. Preoperative treatment with lamivudine may
decrease the rate o HCV recurrence a er trans-
plantation.
B. HCV is second to hepatitis B (HBV) as the most
common indication or liver transplantation
worldwide.
C. Up to 30% o patients with active hepatitis C at
the time o transplant will experience recurrence
o HCV in the transplanted liver.
D. T e Model or End-Stage Liver Disease (MELD)
score assessment predicts perioperative mortal-
ity o transplant recipients.
E. Post-transplantation, progression o HCV in ec-
tion to cirrhosis is more aggressive than the orig-
inal in ection.
2. Which of the following is a contraindication to liver
transplantation in a patient with hepatocellular
carcinoma (HCC)?
A. Portal vein thrombosis
B. Presence o hepatorenal syndrome
C. T ree tumors within hepatic parenchyma mea-
suring 2.7 cm, 2 cm, and 1.5 cm
D. Solitary HCC nodule in peripheral lung measur-
ing 1 cm
E. HIV in ection
A previously healthy 24-year-old patient is admit-
ted with a two-day history o malaise, nausea, vom-
iting, jaundice, and epigastric pain. Over the next
three days, she becomes increasingly con used, then
obtunded, with associated marked elevation in liver
enzymes, bilirubin, and ammonia levels. INR rises to
7.1 and Cr is 4.3 mg/dL.
3. Which of the following is true with regards to liver
transplantation in this patient?
A. Alcohol-induced hepatitis is the most likely
underlying etiology o this patients condition.
B. Without transplantation, the mortality rate asso-
ciated with this condition approaches 80%.
C. Emergent transplantation is contraindicated due
to severe coagulopathy.
D. T e MELD score assessment will be used to
determine the patients priority on the transplant
waiting list.
E. One-year survival is higher a er transplantation
or ulminant hepatic ailure than or chronic
liver ailure.
T e above patient undergoes orthotopic liver
transplantation. On the rst post-operative day, the
patient demonstrates no improvement in mental
status. Laboratory analysis is notable or acidosis,
marked elevation in liver enzymes, elevated INR,
and hyperkalemia. Minimal output is noted rom the
-tube biliary drainage catheter.

4. T e most likely etiology for this clinical presenta-
tion is:
A. Acute cell-mediated rejection.
B. Bacterial sepsis.
C. Primary non- unction o gra .
D. Biliary anastomotic leak.
E. Acute viral hepatitis.
5. T e best treatment for the above condition is:
A. Increase in tacrolimus dose.
B. High-dose intravenous corticosteroids.
C. Inter eron with ribavirin.
D. ERCP with biliary stenting.
E. Re-transplantation.
ANSWERS
1. E. Worldwide, HCV is the most common indication
or liver transplantation. Following liver transplan-
tation, the majority o patients with positive HCV
titers will experience recurrence o hepatitis C in the
transplanted liver. Pre-operative therapy with inter-
eron and ribavirin is help ul in managing symp-
toms o early HCV in ection, but will only achieve
viral clearance rom serum in a small percentage
o patients. Lamivudine is used in post-transplant
patients with HBV and has been shown to signi -
cantly improve survival rates and overall outcomes.
When hepatitis C recurs in the transplanted liver,
the progression to cirrhosis is much more aggressive
than the original in ection, and patients can progress
to end-stage liver ailure in 6 months. T e MELD
ormula is calculated using logarithms o the serum
creatinine, bilirubin, and INR. T e MELD score pre-
dicts the likelihood o death i the patient does not
receive liver transplantation, but does not correlate
with non-transplant post-operative survival rates.
2. D. T e majority o HCC tumors develop in patients
with cirrhosis. While liver resection is the treat-
ment o choice or HCC in patients without cir-
rhosis, orthotopic liver transplantation (OL ) has
evolved as the pre erred treatment or HCC in the
setting o advanced cirrhosis as OL treats both the
tumor and underlying liver dys unction. T e Milan
criteria guides patient selection or liver transplan-
tation; patients with a solitary tumor up to 5 cm or
three tumors up to 3 cm each are eligible or OL .
Metastatic HCC is an absolute contraindication
to transplantation. Portal vein thrombosis is not
C H AP TER 8 5 TRAn s P l An T s u Rg ERy l i v ER 325
a contraindication to OL because the thrombus
can be extracted, or a jump gra can be placed to
the superior mesenteric vein (SMV). Patients with
hepatorenal syndrome may experience recovery o
renal unction ollowing liver transplantation; even
in advanced cases the patient may be a candidate or
combined liver-kidney transplantation. HIV is no
longer considered an absolute contraindication to
OL provided it is well controlled with antiretroviral
therapy, but active sepsis remains a contraindication.
3. B. Fulminant hepatic ailure is de ned as the pres-
ence o encephalopathy within 8 weeks o the devel-
opment o jaundice in the absence o previous liver
disease. In the United States and Europe, the most
common cause o ulminant hepatic ailure is aceta-
minophen overdose. T e Kings College criteria are
the most widely accepted guideline or transplan-
tation o patients with ulminant hepatic ailure.
According to the Kings College criteria, a patient
with ulminant hepatic ailure secondary to aceta-
minophen overdose quali es or transplantation i
either pH < 7.3, or all three o the ollowing crite-
ria are met: grade 34 encephalopathy, P > 100 s or
INR > 6.5 (choice C is alse), or Cr > 3.4 mg/dL. In
non-acetaminophen overdose, the criteria are either
P > 100 s (i.e., INR > 6.5), or any three o the ollow-
ing: age < 10 or > 40 y, non-A/non-B/drug-induced/
Wilson disease hepatitis, greater than 7-day transi-
tion rom jaundice to encephalopathy, P > 50 s (i.e.,
INR > 3.5), or total bilirubin > 17.5 mg/dL. Regard-
less o etiology, the patient in this scenario meets
Kings College criteria or transplantation based on
her severe encephalopathy, INR, and creatinine level.
Without transplantation, the mortality rom ul-
minant hepatic ailure approaches 80%. While the
MELD score can be additive to the Kings College
criteria in predicting mortality, and is used to assign
priority on the transplant waiting list or patients
with chronic liver ailure, patients with ulminant
hepatic ailure are listed as status 1A (highest prior-
ity), which supersedes the MELD score assessment.
Survival a er transplantation or ulminant hepatic
ailure is lower at 1 year compared to transplantation
or chronic liver ailure: 73% versus 85%.
4. C. Primary non- unction o the transplanted
liver occurs in 2% to 10% o cases and is character-
ized by absence o bile production, severe acidosis,
elevation o liver enzymes, hyperkalemia, hepatic
326 g En ERAl s u Rg ERy EXAM i n ATi O n An D BO ARD REv i EW
encephalopathy, and eventually multi-organ ailure.
Possible etiologies are early hepatic arterial throm-
bosis, prolonged ischemia o the donor liver, poor
preservation, advanced donor age, or allogra stea-
tosis. Acute cell-mediated rejection a er liver trans-
plantation is a less common cause o gra loss than
primary non- unction or hepatic artery thrombosis.
Rejection may be asymptomatic, or may present with
mild symptoms mimicking hepatitis. In act, recur-
rent hepatitis C may occur in the early post-operative
period due to the immunosuppressive regimen and be
dif cult to distinguish rom acute rejection, although
a biopsy can be help ul in this regard. Intra-abdominal
sepsis may occur, mani esting with ever and peritoni-
tis, and is most o en due to biliary anastomotic leak.
Biliary leak or stricture is a common post-operative
complication occurring in 10% to 30% o cases, and
is diagnosed via cholangiography.
5. E. Patients with primary non- unction o the gra
are essentially anhepatic, and a majority require re-
transplantation; patients are relisted as Status 1A.
High-dose intravenous corticosteroids are the treat-
ment or acute cell-mediated rejection, except in
patients with underlying hepatitis C. T ese patients
should minimize steroids as much as possible to
decrease viral replication, and should instead receive
an increase in their tacrolimus or mycophenolate
mo etil dose. Patients with recurrent hepatitis C may
be treated with a combination o inter eron and riba-
virin. ERCP with biliary stenting is the treatment o
choice or a biliary leak or stricture.
BIBLIOGRAPHY
Ascher NL. Liver transplantation. In: ownsend CM, Beau-
champ D, Evers BM, Mattox KL, eds. Sabiston extbook o
Surgery: T e Biological Basis o Modern Surgical Practice.
19th ed. Philadelphia, PA: Elsevier; 2012:65565.
Locke JE, Cameron AM. reatment or hepatocellular carci-
noma: Resection versus transplantation. In: Cameron JL,
Cameron AM, eds. Current Surgical T erapy. 11th ed. Phil-
adelphia, PA: Elsevier; 2014:3345.
Roberts MS, Angus DC, Bryce CL, Valenta Z, Weiss eld L.
Survival a er liver transplantation in the United States:
A disease-speci c analysis o the UNOS database. Liver
ranspl. 2004;10(7):88697.
Welling H, Pelletier SJ. Hepatic transplantation. In: Mulhol-
land MW, Lillemoe KD, Doherty GM, et al., eds. Greenf elds
Surgery: Scientif c Principles and Practice. 5th ed. Philadel-
phia, PA: Lippincott Williams & Wilkins; 2011:54264.
Vasc ul a r Sur ger y
Dwight C. Kellicut
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 86
Carotid Occlusion
ony Katras
A 62-year-old male is re erred to your o ce or evalu-
ation o an asymptomatic le carotid bruit. He has no
history o transient ischemic attack ( IA) or stroke.
Carotid duplex scanning reveals an occluded right
internal carotid artery, and elevated ow velocities in
the le internal carotid (peak systolic o 510 cm/sec and
end diastolic o 185 cm/sec). Computerized tomogra-
phy (C ) angiography con rms occlusion o the right
internal carotid artery and > 80% stenosis o the le
internal carotid artery. An EKG and a nuclear medicine
cardiac stress test are both normal.
1. T e best treatment option or this patient is:
A. Right carotid endarterectomy
B. Le carotid endarterectomy
C. Staged bilateral carotid endarterectomy
D. Bilateral carotid stents
E. Medical treatment without surgery will give pt
the best chance or avoiding a stroke
2. T e patient did not want surgery and opted
or medical management. One week later he
presents to the emergency room ten hours a er
experiencing a le hemispheric IA. He now has
no neurological def cits. C scanning shows no
evidence o cerebral in arction. Duplex scan now
shows occlusion o both internal carotid arteries.
T e best treatment plan is:
A. reat the patient with anti-platelet therapy and
manage non-operatively.
B. Fully anti-coagulate the patient with heparin/
Coumadin and manage non-operatively.
C. Obtain a C angiogram. I the internal carotid is
patent, even i 99% stenotic, per orm an urgent
le carotid endarterectomy.
D. Obtain a C angiogram. I the le internal
carotid is indeed occluded, wait 4 weeks and per-
orm a le carotid endarterectomy.
E. Obtain a C angiogram. I the le internal
carotid is indeed occluded, per orm a le extra-
cranial to intra-cranial bypass.
3. T e patient eventually undergoes carotid
endarterectomy (CEA) with prosthetic patch
closure. He is initially awake and alert in the
recovery room but 1 hour later he develops new
onset aphasia and right arm weakness. What do
you recommend as the next step?
A. Observation
B. Systemic anticoagulation administration
C. Systemic thrombolytic administration
D. Immediate return to the operating room
E. C angiogram
4. During surgical exposure o the carotid artery
the patient becomes severely bradycardic. Only
occasional beats with long pauses are visible on
the cardiac monitor. Which o the ollowing is the
most appropriate next step?
A. Abort procedure
B. Administer IV atropine
C. Electrical cardioversion
D. Administer norepinephrine
E. ransect the vagus nerve
330 G EN ERAL S U RG ERY EXAM I N ATIO N AN D BO ARD REVI EW
5. Which o the ollowing is an indication or
emergency carotid endarterectomy?
A. Asymptomatic patient with an 80%99% inter-
nal carotid artery stenosis.
B. Severe stroke with an 80%99% stenosis.
C. ransient monocular blindness (amaurosis
ugax) with an 80%99% stenosis.
D. Crescendo transient ischemic attacks ( IA) with
a 60%79% stenosis.
E. IA due to tandem lesions o the carotid bi urca-
tion and intracranial carotid siphon.
ANSWERS
1. B. T e correct answer is a carotid endarterectomy
(CEA) on the side with high grade stenosis. CEA
is not indicated on occluded carotid arteries. Even
i CEA is possible on total occlusions, the patient
would be at a higher risk or perioperative stroke due
to reper usion injury, thus a CEA should not be per-
ormed on a chronic occlusion. T e same holds true
or carotid stenting. Due to the severity o disease,
CEA is a better option than medical management
alone as many randomized clinical trials have shown.
2. C. Because it is o en di cult to dif erentiate
between occlusion and near occlusion (string sign)
with carotid duplex scanning, best practice is to con-
rm with angiography (usually C A) whether the
ICA is patent or not. T us i there is a string sign with
trickle carotid ow, urgent carotid endarterectomy
is indicated. I the carotid is indeed occluded, most
vascular surgeons would choose antiplatelet therapy
or long term treatment. CEA is not per ormed on
occluded ICAs due to increased risk or stroke sec-
ondary to reper usion injury. Extra-cranial to intra-
cranial bypass has no bene t over medical therapy
alone. T is procedure is rarely per ormed today, with
only very ew indications.
3. D. Most surgeons recommend immediate re-
operation or patients with new onset neurological
events in the recovery room ollowing CEA. T e
purpose o operative exploration is to correct any
surgical de ect and to restore blood ow as soon as
possible i thrombotic occlusion is ound. Intraop-
erative angiography is pre erred by many surgeons
either be ore or a er surgical re-exploration. Intraop-
erative duplex ultrasound may also be used to exam-
ine the operative site or abnormal ow or intimal
aps. Magnetic resonance imaging (MRI) and/or C
scans are generally reserved or urther evaluation
a er con rmation o a patent carotid repair. Most
surgeons would not recommend systemic thrombo-
lytic agents due to the risk o hemorrhage.
4. B. T e carotid sinus, located in the distal common
carotid artery, is a collection o baroreceptor tissue
that, when stimulated by increase pressure, produces
bradycardia and hypotension. T e carotid sinus is
innervated by the carotid sinus nerve (nerve o Her-
ing), which arises rom the glossopharyngeal nerve.
During a carotid endarterectomy, particularly dur-
ing dissection near the bulb or with manipulation
o the plaque, the carotid sinus may be stimulated
leading to bradycardia and even asystole. Some sur-
geons routinely inject the tissue near the sinus with
lidocaine. I bradycardia occurs in a bulb that has not
been anesthetized, lidocaine can be employed. I the
patient experiences severe bradycardia and loses a
pulse, atropine should be administered immediately
along with epinephrine as needed.
5. D. Crescendo IAs represent unstable plaque and
call or an emergent carotid endarterectomy. T e ret-
inal in arction rom carotid stenosis is certainly an
indication or carotid endarterectomy but not nec-
essarily on an emergent basis. Asymptomatic high
grade carotid artery stenosis does not require emer-
gent surgery. A er a severe stroke, there is usually an
interval o recovery be ore endarterectomy should
be considered, the exact length o which remains
debated. Most now believe that waiting longer than
2 to 4 weeks places the patient at an unnecessary
risk o recurrent stroke. IAs with a carotid stenosis
should be treated aggressively whether it is associ-
ated with an intracranial stenosis or not, but this is
not considered an indication or emergent surgery.
BIBLIOGRAPHY
Moore WS. Extracranial cerebrovascular disease. In: Moore
WS. Vascular and Endovascular Surgery. 7th ed. Philadel-
phia, PA: Elsevier Saunders; 2006:61758.
Naylor AR. Surgical treatment o carotid disease. In: Hallet
JW, Mills JL, Earnshaw JJ, eds. Comprehensive Vascular and
Endovascular Surgery. 2nd ed. Philadelphia, PA. Mosby;
2009:60629.
Pine R, Avellone JC, Hof man M, Plecha FR, Swayngim DM,
Urban J. American Journal of Surgery. June 1984;147(6):
7635.
Ricotta JJ, AbuRhama A, Ascher E, Escandan M, Faries P, Lai
BK. Updated society or vascular surgery guidelines or
management o extracranial carotid disease. Journal of
Vascular Surgery. September 2011;54(3):e131.
 87
Abdominal Aortic Aneurysm

Dwight C. Kellicut

A 63-year-old male with past medical history signi cant 4. Regarding survival af er endovascular repair
or well controlled hypertension, hyperlipidemia, and a (EVAR), compared with open repair, which o the
remote history o smoking is re erred or evaluation o ollowing is true?
a 5.7 cm in rarenal abdominal aortic aneurysm (AAA) A. EVAR demonstrates equal survival both in the
ound incidentally on a C scan o the abdomen during rst 30 days and long term.
a recent emergency room visit or abdominal pain. B. EVAR demonstrates better long term survival
T e patient recently underwent a cardiac stress test and equal 30 day survival.
by his primary care physician, which was normal and C. EVAR demonstrates better 30 day survival and
is now being considered or open versus endovascular no di erence in long term survival.
repair. D. In patients with minimal, well-controlled comor-
bidities, EVAR provides the better long-term
1. Which o the ollowing is considered a major risk
results.
actor in the development o AAA?
E. In patients with poorly controlled co-morbidities,
A. Diabetes mellitus the open repair has a 15% mortality rate.
B. Hypertension
C. Smoking
D. Collagen vascular disease ANSWERS
E. Obesity 1. C. T e major risk actors associated with increased
likelihood o aneurysm ormation include: age > 65,
2. For patients with major risk actors, what would be
male gender, history o smoking, and amily history
the best method to screen or AAA?
o AAA in a rst degree relative.
A. Physical exam
B. Abdominal ultrasound 2. B. For patients with major risk actors, the ques-
C. C scan tion becomes what is the best methodology to detect
D. MRI aneurysms in regard to screening? In the U.S. Preven-
E. Angiography tative Services ask Force (USPS F) January 2014
bulletin, the ollowing recommendations were made:
3. Regarding the size o his aneurysm, when should an the ask Force ound that one-time AAA screening
elective abdominal aortic aneurysm be repaired? can be e ective and recommends it or men ages
A. 4.5 cm 65 to 75 who have ever smoked. T is is a B recom-
B. 5 cm mendation. For men ages 65 to 75 who have never
C. 5.5 cm smoked, the ask Force recommends that these men
D. 6.0 cm talk to their doctor or nurse about whether one-time
332 G EN ERAL S U RG ERY EXAM IN ATI O N AN D BO ARD REVIEW
AAA screening might be right or them based on
their health history and the potential bene ts and
harms o screening.
For women, the ask Force ound that the ben-
e ts and harms o screening are di erent. In the dra
recommendation statement, the ask Force calls or
more research to determine i AAA screening is ben-
e cial or women ages 65 to 75 who smoke or have
smoked in the past. Based on the lack o evidence, the
ask Force determined it could not recommend or
or against screening older emale smokers and issued
an I statement (issued when evidence is insu cient
to ully assess bene ts and harms). Research is criti-
cally needed in this area to determine i AAA screen-
ing could be bene cial or women who smoke or
who have ever smoked. Among nonsmoking women,
the chance o developing AAA is extremely low
(well under 1%), and the ask Force ound that AAA
screening is very unlikely to bene t these women
and may even cause harm. T e ask Force recom-
mends against screening or AAA in these women;
this is a D recommendation.
Physical examination is highly dependent upon
the experience o the examiner and on patient body
habitus. As a general rule, patients with a 5.0 cm AAA
are palpable 75% o the time and those measuring
3.0 to 3.9 cm are palpable 25% o the time. Abdomi-
nal ultrasound has been evaluated in numerous
studies and has been ound to be available, accurate,
and low cost. C and MRI are excellent modalities
or evaluating the aorta regarding accuracy, but ail
on cost e ectiveness and availability. Angiography
actually underestimates the size o a AAA because it
only outlines the arterial lumen. It is also not cost-
e ective as a screening tool.
3. C. T e natural history o AAA is such that most
aneurysms expand at a rate o 0.3 cm/year. wo ran-
domized, prospective trials have demonstrated that
there is no survival bene t to repairing AAA < 5.5 cm,
even in well selected patients who are considered to
have a avorable operative risk. All aneurysms greater
than 4.0 cm should be ollowed on a yearly basis.
For patients who have an aneurysm that measures
greater than 4.0 cm, but less than 5.5 cm, their aneu-
rysm should be ollowed every six months as approx-
imately 25% o those aneurysms will expand at a rate
greater than or equal to 0.5 cm in six months, an indi-
cation or repair. Other indications to repair an AAA
less than 5.5 cm include embolization, occlusion,
symptoms (back/abdominal pain/tenderness on
exam), and patients located in a remote area.
4. C. As a general rule, patients may be considered or
open aortic surgery i they are under the age o 65,
provided they are an acceptable surgical risk. EVAR
may also be considered, but multiple anatomic con-
siderations must be taken into account to include:
neck diameter, neck length, angulation o neck,
reverse taper o neck, calci cation, thrombus, diam-
eter o common emoral/iliac arteries, distal seal
length, iliac tortuosity, and renal/splanchnic blood
f ow. Given all o the technical considerations associ-
ated with EVAR, there are signi cant immediate and
late complications that include device ailure, arterial
embolization, limb thrombosis, gra migration, gra
in ection, and endoleaks.
wo trials (EVAR I and DREAM) have com-
pared open aortic surgery versus EVAR in patients
considered t or open surgery. In both studies
(EVAR I/DREAM), open surgical repair was ound
to have increased 30 day mortality (4.7%/4.6% vs.
1.7%/1.2%), increased blood loss, longer operative
time, and increased blood trans usion. T e long term
survival between open surgery and EVAR have been
shown to be equal. EVAR demonstrates signi cant
gra related complications (41% vs. 9%) and higher
revision rates (20% vs. 6%) making open surgery in
this case a better long term option. T e EVAR 2 trial
ound patients deemed un t, de ned somewhat neb-
ulously, or open surgery had the substantial opera-
tive mortality o 7%, indicating that those patients
that are high risk will remain high risk regardless o
what procedure is chosen. O note, both EVAR 1 and
DREAM excluded emergent cases.
BIBLIOGRAPHY
Abdominal Aortic Aneurysm: Screening. U.S. Preventative
Services ask Force Web site. http://www.uspreventiveser-
vicestask orce.org/uspst 14/abdoman/abdomandra trec.
Released June 2014. Accessed May 15, 2015.
Endovascular Aneurysm rial Participants. Comparison o
endovascular aneurysm repair with open repair in patients
with abdominal aortic aneurysm (EVAR I rial): Random-
ized controlled trial. Lancet. 2004;365:1179.
Endovascular Aneurysm rial Participants. Endovascular
Aneurysm Repair and outcome in patients un t or open
repair o abdominal aortic aneurysm (EVAR trial 2): Ran-
domized controlled trial. Lancet. 2005;365:9478.
Fink HA, Lederle FA, Roth CS, et al. T e accuracy o physical
examination to detect abdominal aortic aneurysm. Arch
Int Med. 2000;160:8336.

Fleming C, Whitlock EP, Beil , Lederle FA. Screening or
abdominal aortic aneurysm: A systematic review and
meta-analysis or the U.S. Preventative Services ask Force.
Ann Intern Med. 2005;142:20311.
Kim LG, Scott RAP, Ashton HA, T ompson SG. A sustained
mortality bene t rom screening or abdominal aortic
aneurysm. Ann Intern Med. 2007;146(10):699706.
Lederle FA, Johnson GR, Wilson SE, et al., or the Aneu-
rysm Detection and Management Study screening pro-
gram: Validation cohort and nal results. Arch Int Med.
2000;160:142530.
Lederle FA, Wilson SE, Johnson GR, et al., or the Aneurysm
Detection and Management (ADAM) Veterans A airs
Cooperative Study Investigators. Immediate repair com-
pared with surveillance o small abdominal aortic aneu-
rysms. N Engl Med. 2002;346:11437444.
C H AP TER 8 7 ABD O M I N AL AO RTI C AN EU RYS M 333
Lederle FA, Johnson GR, Wilson SE, et al., or the Aneurysm
Detection and Management (ADAM) Veterans A airs
Cooperative Study Investigators. Relationship o age, gen-
der, race, and body size on in rarenal aortic diameter. J Vasc
Surg. 1997;26:595601.
Nevitt MP, Ballard DJ, Hallett JW. Prognosis o abdominal
aortic aneurysms: A population based study. N Engl J Med.
1989;321:100914.
Prinssen M, Verhoeven ELG, Buth J, et al. A randomized trial
comparing conventional and endovascular repair o aortic
aneurysms. N Engl J Med. 2004;351:1607.
U.K. Small Aneurysm rial Participants. Mortality results or
randomized controlled trial o early elective surgery or
ultrasonographic surveillance or small abdominal aortic
aneurysms. Lancet. 1998;352:164955.
 88
Vascular Access
Booker . King
1. A 65-year-old male with end-stage renal disease
has recently had an autogenous right radial-
cephalic arteriovenous (AV) stula per ormed. T e
patient will require temporary dialysis access until
the stula matures. T e best option or temporary
access is:
A. A cu ed, tunneled central venous dialysis cath-
eter in the ipsilateral internal jugular vein.
B. A cu ed, tunneled central venous dialysis
catheter in the contralateral subclavian vein.
C. A cu ed, tunneled central venous dialysis cath-
eter in the contralateral internal jugular vein.
D. An uncu ed central venous dialysis catheter in
the right emoral vein.
E. An uncu ed central venous dialysis catheter in
the contralateral internal jugular vein.
2. You are evaluating a patient or an autogenous
AV stula or long-term dialysis access. T e
patient has no Doppler signal in the right palmar
arch and urther work-up con rms stenosis o
the ulnar artery on that side. T e patient has a
lef subclavian central venous dialysis catheter
currently. Vascular evaluation o the lef arm
and hand was unremarkable. What is the best
option or long term dialysis access in this
patient?
A. Placement o a radial-cephalic AV stula in the
contralateral arm.
B. Placement o a brachial-basilic AV stula in the
ipsilateral upper arm as the more proximal loca-
tion will not be a ected by the ulnar artery ste-
nosis.
C. Placement o a long term central venous dialysis
catheter (Permacath).
D. Placement o a emoral-saphenous AV stula in
the le groin.
E. rans er the dialysis catheter to the ipsilateral
internal jugular vein and placement o a radial-
cephalic AV stula in the contralateral arm.
3. A 67-year-old male with end stage renal disease
returns to your vascular clinic six weeks af er he
had a lef autogenous radial-basilic AV stula
per ormed. He complains o intractable pain in his
lef hand and that hand is colder. He also has dark,
dry ulcers o the distal end o ngers 2 to 4. What
is the most likely cause o this condition?
A. Emboli that has travelled rom plaque that has
ormed in the radial artery.
B. Arterial ow is being shunted away rom the
radial artery into the venous out ow o the AV
stula.
C. An air embolus inadvertently ormed in the
radial artery rom air trapped in the dialysis cir-
cuit that has travelled to the arterial system o
the hand.
D. An unrecognized arterial stenosis in the radial
artery that has become symptomatic.
E. Intermittent vasospasm o the radial artery
brought on by hemodialysis.
4. T e most appropriate treatment or the condition
in question # 3 is:
A. Angioplasty and possible stenting o any stenosis
in the arterial limb o the AV stula.

B. Intra-arterial injection o papaverin into the AV
stula and a three month course o an oral cal-
cium channel blocker post-procedure.
C. Ligate the radial artery distal to the AV stula.
D. T erapeutic heparinization and then War arin
therapy or 3 months or treatment o embolic
disease.
E. Reassure the patient that the condition is sel -
limiting and will improve over the next ew
weeks.
5. A 50-year-old male presents with ever to 102.5F
and malaise two months af er placement o a
prosthetic AV stula in his right orearm. T e
patient has erythema around the AV stula
incision site and the AV stula is warm and pain ul
upon palpation. Blood cultures were obtained
and preliminary Grams stain show large amount
o Gram positive cocci in clusters. A course o
intravenous Vancomycin and Ce epime was
started. What is the next step in the management
o this patient?
A. Schedule surgery urgently or the removal o
prosthetic material rom the right orearm.
B. Continue intravenous Vancomycin or a our
week course in an attempt to sterilize the AV
stula.
C. Inject Vancomycin and Ce epime into the AV
stula directly and place a tourniquet above the
stula or 30 minutes.
D. Start an eight day course o Vancomycin and
Ce epime and then repeat blood cultures. No
additional therapy is needed i blood cultures are
negative.
E. Surgically remove prosthetic material rom the
right orearm and placement o an autogenous
ipsilateral brachial-basilic AV stula concur-
rently during this operation.
ANSWERS
1. C. Cu ed, tunneled dialysis catheter can be main-
tained or 6 weeks or more while uncu ed catheters
will need to be replaced at 3 weeks. An autogenous
AV stula will usually take 4 to 6 weeks to mature.
Catheters placed in the ipsilateral internal jugu-
lar vein or either subclavian vein are associated
with higher rates o AV stula ailure due to par-
tial venous out ow obstruction. T ere is negligible
risk o venous out ow obstruction with temporary
C H AP TER 8 8 VAs C u l AR ACC Es s 335
dialysis catheter placed in the contralateral internal
jugular vein. Catheter placement in the emoral vein
is not ideal especially in patients who are ambulatory.
Femoral venous catheters have been associated with
higher rates o venous thrombosis and blood stream
in ections in several reports.
2. E. AV stula placement anywhere in the ipsilateral
arm is not prudent given the stenosis o the ulnar
artery on that side. T is option has a high risk o gra
ailure. Femoral-saphenous AV stula is an in erior
option due to increased risk o gra thrombosis and
in ection in this location. AV stula placement in the
contralateral arm is the best option but the tempo-
rary dialysis should be trans erred to the right inter-
nal jugular vein to maximize long term patency.
3. B. T e arterial insuf ciency that is seen in this
patient is an example o ischemic steal syndrome.
Arterial ow is being diverted away rom the hand
into the venous out ow (in this case the basilic vein).
T is phenomenon occurs in all AV stulas to some
degree but in rare cases the arterial insuf ciency is
to such a degree that the condition becomes symp-
tomatic. Patients usually present with severe pain in
the hand (or oot in the case o emoral-saphenous
AV stulas). T is can progress to ischemic ulcers
orming on the distal extremity. T e diagnosis can be
con rmed by Doppler imaging or venograpy.
4. A. Be ore ligating the radial artery, standard o care
is or an arteriogram o the in ow artery with pos-
sible balloon angioplasty and/or stenting. I treat-
ment o the arterial in ow with angioplasty and/or
stenting does not correct the problem, then either a
distal revascularization and interval ligation (DRIL)
procedure or Proximalization procedure would be
indicated. Ligation o the radial artery should only
be considered a last resort. Ligation will allow arte-
rial ow to be restored to the palmar arch and hand.
Alternatively, or more proximal upper extremity
and lower extremity AV stulas, distal revasculariza-
tion with interval ligation or DRIL procedure can be
per ormed. In this procedure, a conduit (usually the
saphenous vein gra ) is created rom the proximal
portion o the arterial limb o the AV stula to an
area on the artery distal to the stula. A erwards, the
artery is ligated between the stula and the bypass
gra . T is procedure will usually allow preservation
o the AV stula as well as treat the arterial steal. I
336 G EN ERAl s u RG ERY EXAM I N ATIO N AN D BO ARD REVI EW
these measures ail to correct the problem, the AV
stula will need to be ligated. Banding or plication o
the venous out ow limb are less invasive procedures
that have been used to treat this condition.
5. A. T e patient in question #5 has an in ected AV s-
tula gra . T is patient also has bacteremia as result
o the gra in ection and is at risk to develop severe
sepsis which can lead to death i not treated appro-
priately and expeditiously. Antibiotic therapy should
be introduced immediately and empiric broad spec-
trum antibiotics are advised since the patient has
likely been exposed to resistant hospital pathogens. In
this case methicillin-resistant Staphylococcus Aureus
(MRSA) is the most likely pathogen and Vancomy-
cin is directed against it. T e prosthetic material in
the gra is the source o the in ection and there ore
must be removed. Any attempt to eradicate the gra
in ection with antibiotic therapy alone will ail. T e
placement o a new autogenous AV stula should be
postponed until the in ection is adequately treated.
BIBLIOGRAPHY
Berman SS, Gentile A , Glickman MH et al. Distal revascular-
ization: Interval ligation or limb salvage and maintenance
o dialysis access in ischemic steal syndrome. J Vasc Surg.
1997;26(3):393404.
Jennings WC, Kindred MG, Broughan A. Creating radioce-
phalic arteriovenous stulas: echnical and unctional suc-
cess. J Am Coll Surg. 2009;208:41925.
Joynt GM, Kew J, Gomersall CD, et al. Deep venous thrombo-
sis caused by emoral venous catheters in critically ill adult
patients. Chest. 2000;117:17883.
La rance JP, Rahme E, Lelorier J, et al. Vascular access-related
in ections: De nitions, incidence, and risk actors. Am J
Kidney Dis. 2008;52(5):98293.
Malik J, uka V, Kasalova Z, Chytilova E, Slavikova M, Clagett
P, et al. Understanding the dialysis access steal syn-
drome. A review o the etiologies, diagnosis, prevention
and treatment strategies. J Vasc Access. JulySeptember
2008;9(3):15566.
Merrer J, De Jonghe B, Golliot F, et al. Complications o
emoral and subclavian venous catheterization in criti-
cally ill patients: a randomized controlled trial. JAMA.
2001;286(6):700707.
Schwab SJ, Beathard G. T e hemodialysis catheter conun-
drum: Hate to live with them but cant live without them.
Kidney Int. 1999;56:117.
ashjian DB, Lipkowitz GS, Madden RL, et al. Sa ety and ef -
cacy o emoral- based hemodialysis access gra s. J Vasc
Surg. 2002;35:6913.
Yaghoubian A, de Virgilio C. Plication as a primary treatment
o steal syndrome in arteriovenous stulas. Ann Vasc Surg.
2009;23(1):1037.
 89
Complications o Hemodialysis
Alexander Malloy
A 66-year-old male with end-stage renal disease, coro-
nary artery disease, diabetes, and hypertension presents
to his outpatient clinic or regularly scheduled hemodi-
alysis. He has a unctioning le brachiocephalic arterio-
venous stula that his nurse accesses without di culty.
His dry weight is 80 kg.
1. A er initiating hemodialysis, the patient begins
to complain o muscle cramps in his legs. Which
o the ollowing is an e ective treatment or this
condition?
A. Having the patient drink water during hemodi-
alysis
B. Hypertonic saline
C. A low-sodium dialysate
D. Increasing the ultra ltration rate
E. Permissive hypotension
2. T e patient continues his hemodialysis. He
becomes acutely hypotensive. Which o the
ollowing could be a cause o hypotension?
A. Fasting in the peri-hemodialysis period
B. Increased sympathetic tone
C. Hemolysis
D. Low ultra ltration rate
E. Cooling o the dialysate solution
3. T e patients hypotension has resolved, but he is
now experiencing dyspnea and chest pain. What is
the appropriate management or this patient?
A. Electrocardiogram and serum cardiac enzymes
B. Continuation o dialysis
C. Reduction o ultra ltration rate
D. Both A and C
E. All o the above
4. Another patient who undergoes peritoneal dialysis
or end-stage renal disease develops peritonitis.
T e patient is otherwise hemodynamically normal,
without volume overload or signif cant electrolyte
abnormality. What is the recommended treatment?
A. Laparotomy and peritoneal washout
B. Peritoneal dialysis catheter removal
C. Empiric gram negative and gram positive cover-
age with intraperitoneal and oral antibiotics
D. Empiric gram negative, gram positive, and anti-
ungal intravenous coverage
E. Emergent temporary dialysis catheter placement
and initiation o hemodialysis
5. T is patients peritonitis does not improve, and
yeast is isolated on the gram stain. What is the
recommended management o this patient?
A. Peritoneal lavage, intraperitoneal uconazole,
and catheter removal
B. Catheter removal and intravenous uconazole
C. Intraperitoneal amphotericin B ollowed by
catheter removal
D. Peritoneal lavage ollowed by catheter removal
E. Catheter removal and immediate hemodialysis
ANSWERS
1. B. Dialysis-associated muscle cramps is a common
problem that af ects up to 86% o patients. T e true
etiology o the muscle cramps is not well understood,
338 G EN ERAL S U RG ERY EXAM IN ATIO N AN D BO ARD REVI EW
but is likely related to electrolyte and uid uctua-
tions. T ese reactions can occur when a low-sodium
dialysate is used resulting in hyponatremia or hypo-
osmolar plasma states. T is can be avoided by using
a dialysate with a higher concentration o sodium.
Cramps o en occur due to rapid increase o inter-
dialytic weight gains leading to intravascular volume
contraction and hypo-osmolality as a result o high
ultra ltration rates. Hypertonic saline or hypertonic
dextrose in a non-diabetic patient have been shown as
ef ective treatments to counteract the hypo-osmolar
state o the intravascular uid, and also be help ul in
hypovolemic states that may precipitate cramping or
other serious reactions. Drinking water would not
be ef ective in reversing a hypo-osmolar state and
would not alleviate muscle cramps.
2. C. Intradialytic hypotension is one o the most com-
mon complications o hemodialysis, occurring in up
to 30% o patients. T ere are many causes o hypo-
tension in the dialysis patient that can lead to li e-
threatening scenarios such as arrhythmia, bleeding,
in ection, and myocardial in arction, among others.
Hypotension can occur rom aggressive ultra ltra-
tion or hypo-osmolar dialysate resulting in weight
gain. Low ultra ltration rates do not typically cause
hypotension (Choice D). Ingestion o a large meal
immediately prior to or during dialysis can direct
blood ow to splanchnic circulation and result in
peripheral hypotension; as a result, eating in the
peri-dialysis period is not recommended (Choice
A). Autonomic dys unction and neuropathy related
to long-standing diabetes mellitus o en results in
hemodynamic instability during dialysis, which has
been reported in up to 50% o patients (Choice B).
Hemolysis can occur i the dialysate solution is con-
taminated with bacteria or other minerals, as well
as i the solution is hypotonic. I hemolysis occurs,
the pathognomonic sign is a port-wine appearance
o blood in venous lines (Choice C). Hemolysis is
usually accompanied by other symptoms such as
nonspeci c chest pain and dyspnea. Hemolysis can
lead to hyperkalemia and arrhythmia i not properly
identi ed and treated. Hypotension can be precipi-
tated by warm dialysate and cooling o the solu-
tion is known to prevent such a complication. Fixed
reduction o body temperature by 1C has shown a
statistically signi cant reduction in systolic blood
pressure in several studies. T e mechanism is not
ully understood but lower temperatures are thought
to increase sympathetic activity, thereby maintaining
adequate systemic vascular resistance (Choice E).
3. E. T is patient has coronary artery disease so angina
or myocardial in arction should be ruled out but all
o the above treatments are appropriate. Cardiac
enzymes and electrocardiograms should be obtained
on an individual basis based on clinical scenario
and this patient meets this criteria. Reduction in
ultra ltration will reverse a hypovolemic state, thus
reducing myocardial demand ischemia (Choice C).
Continuation or cessation o dialysis (Choice B) are
both acceptable, but are dependent on clinical actors
such a hemodynamic stability, physical ndings, and
degree o patient com ort.
4. C. Peritonitis is a common complication o perito-
neal dialysis, and is the primary reason or cessation
o peritoneal dialysis with transition to hemodialy-
sis. Peritonitis in patients who undergo peritoneal
dialysis has signi cant morbidity but are managed
with empiric outpatient antibiotics in over 75% o
cases. Current guidelines state that empiric gram
negative and gram positive coverage with antibiot-
ics are indicated. Outpatient antibiotics typically
include intraperitoneal and oral administration,
such as intraperitoneal ce azolin and oral cipro oxa-
cin, but inpatient regimens can include intravenous,
intraperitoneal, or oral modalities (Choice C). Mon-
otherapy is also available in intravenous orm with
imipenem/cilastatin. Empiric anti ungal coverage
is not recommended due to emerging resistance to
anti ungals (Choice D) and a large review revealed
that only 2% o peritoneal dialysis-associated perito-
nitis were rom ungal elements.
Laparotomy would not be recommended even i
the patient were hemodynamically unstable, unless
there was another precipitating cause o peritonitis
such as bowel per oration or hemorrhage (Choice A).
Peritoneal dialysis catheter removal is not a rst line
treatment or microbial peritonitis. Indications or
catheter removal are relapsing peritonitis, lack o
antimicrobial response within ve days o initiation,
or tunnel or insertion sites that involve in ection.
Placement o a temporary dialysis catheter and initi-
ation o hemodialysis is not indicated in this patient
as he is hemodynamically normal without any gross
electrolyte disturbance (Choice E).
 C H AP TER 8 9 CO M P LI C ATIO N S O f H EM O D IALYS I S
5. A. I ungal elements are isolated on gram stain
or culture, prompt removal o the dialysis catheter
and administration o intraperitoneal or intrave-
nous anti ungals should be initiated. Intraperitoneal
amphotericin B is generally not recommended as it
causes additional pain to the patient and is known
or developing signi cant intraperitoneal adhesions.
ypically the peritoneal uid has a grossly cloudy
appearance and should be lavaged with normal saline
until clear. T e patient should undergo hemodialysis
in the near uture or a minimum o six weeks. Imme-
diate hemodialysis is not necessary unless clinically
indicated via signs o acidosis, electrolyte imbalance,
uremia, or uid overload. A er the six week period,
a new peritoneal catheter can be placed i the patient
desires.
BIBLIOGRAPHY
Barakat MM, Nawab ZM, Yu AW, Lau AH, Ing S, Daugir-
das J . Hemodynamic ef ects o intradialytic ood inges-
tion and the ef ects o caf eine. J Am Soc Nephrol. May
1993;3(11):18138.
Canzanello VJ, Burkart JM. Hemodialysis-associated muscle
cramps. Semin Dial. 1992;5:299.
Ewing DJ, Winney R. Autonomic unction in patients with
chronic renal ailure on intermittent haemodialysis. Neph-
ron. 1975;15(6):424.
339
Hernando P, Caramelo C, Lpez Garcia D, Hernando L. Mus-
cle cramps: A cause o elevated creatine kinase levels in
hemodialysis patients. Nephron. 1990;55(2):231.
Li PK, Szeto CC, Piraino B, Bernardini J, Figueiredo AE, Gupta
A, et al. Peritoneal dialysis-related in ections recommenda-
tions: 2010 update. Perit Dial Int. 2010;30(4):393.
Port FK, Held PJ, Nolph KD, urenne MN, Wol e RA. Risk
o peritonitis and technique ailure by CAPD connection
technique: a national study. Kidney Int. 1992;42(4):967.
Sands JJ, Usvyat LA, Sullivan , Segal JH, Zabetakis P, Kotanko
P, et al. Intradialytic hypotension: Frequency, sources o
variation and correlation with clinical outcome. Hemodial
Int. April 2014;18(2):41522. Epub January 27, 2014.
Selby NM, McIntyre CW. A systematic review o the clinical
ef ects o reducing dialysate uid temperature. Nephrol
Dial Transplant. 2006;21(7):1883.
Sherman RA, Goodling KA, Eisinger RP. Acute therapy o
hemodialysis-related muscle cramps. Am J Kidney Dis.
1982;2(2):287.
Sherman RA, Daugirdas J , Ing S. Complications during
hemodialysis. In: Daugirdas J , Ing S. eds. Handbook of
Dialysis. 4th ed. Philadephia, PA: Lippincott Williams and
Wilkins; 2007:170.
Stablein DM, Nolph KD, Lindblad AS. iming and charac-
teristics o multiple peritonitis episodes: A report o the
National CAPD Registry. Am J Kidney Dis. 1989;14(1):44.
Wang AY, Yu AW, Li PK, Lam PK, Leung CB, Lai KN, et al. Fac-
tors predicting outcome o ungal peritonitis in peritoneal
dialysis: Analysis o a 9-year experience o ungal peritoni-
tis in a single center. Am J Kidney Dis. 2000;36(6):1183.
 90
Lymphatic Disease

Robert C. McMurray

A 65-year-old man presents to your clinic with com- 1. T is patient is most likely su ering rom which
plaints o increasing right lower extremity heaviness disease process?
and swelling over the last 2 to 3 months. He states his A. Chronic venous insu ciency
symptoms worsen throughout the day and his shoes eel B. Filariasis
tight by the time he takes them o at night. He denies C. Nephrotic syndrome
any skin changes, wounds, or recent trauma to the area. D. Lymphedema
He also denies any evers, chills, atigue, weight loss, or
weight gain. His past medical history is only signi cant 2. T e most common cause o secondary lymphedema
or hypertension, obesity, and a recent history o mela- worldwide is:
noma o the right lower extremity or which he under- A. Malignancy or a result o its treatment
went resection o the lesion with regional lymph node B. Lymphedema praecox
dissection and has been recovering well. His social his- C. Wuchereria bancro i
tory and amily history are unremarkable and he denies D. Lymphedma tarda
any recent travel.
He has never smoked and denies any alcohol use. He 3. T e best test or diagnosing this patient with
does not exercise regularly and takes an ACE inhibi- suspected lymphedema is:
tor and a multivitamin daily. His vital signs are a tem- A. Lymphangiography
perature o 38C, heart rate o 72 beats per minute, B. Computerized tomography (C ) scan
blood pressure o 135/74 mm Hg, respiratory rate o 14 C. Magnetic resonance imaging (MRI)
breaths per minute, and oxygen saturation o 99% on D. Detailed history and physical exam
room air. Physical examination demonstrates di use E. Lymphoscintigraphy
non-pain ul pitting edema over his right lower extrem-
ity that extends over the dorsum o his oot including 4. T e f rst line treatment o lymphedema consists
his toes. T ere is no evidence o skin discoloration or o:
open wounds. He has easily palpable pulses and good A. Diuretics
capillary re ll. His right lower extremity measures 4 cm B. Lymphatic reconstruction or excision o diseased
greater in circum erence than his le lower extremity. channels
T ere are no palpable masses in his groin. His other C. Compressive therapy
extremities are normal in appearance and the rest o his D. Benzopyrones (Coumarin) and long-term anti-
physical exam is unremarkable. biotics

5. You diagnose this patient with lymphedema and
start him on the appropriate therapy. He returns to
your clinic a ew years later with a pain ul, purplish
ulcerating macule on his right lower extremity.
T is presentation is most concerning or:
A. Lymphangitis
B. Lymphangiosarcoma
C. Hematoma
D. T rombophlebitis
ANSWERS
1. D. T is patient is most likely su ering rom
lymphedema. He is su ering rom unilateral lower
extremity edema, which excludes systemic etiolo-
gies o his edema, such as nephrotic syndrome, liver
disease, and heart ailure. Filariasis is the most com-
mon cause o secondary lymphedema worldwide,
although this patient denies any travel history.
Venous pathology, such as chronic venous insu -
ciency is by ar the most common cause o unilat-
eral lower extremity edema. Lower extremity edema
caused by venous pathology typically presents with
pitting edema that spares the eet. T e prolonged
venous disease the skin can become atrophic with
hemosiderin pigmentation.
T is patient has a history o lower extremity mela-
noma with regional lymph node dissection, which is
a risk actor or developing lymphedema. Other risk
actors include increased body mass index, tumor
location, post-operative in ection or hematoma,
and radiation therapy. Additional malignancies that
have been associated with the development o lym-
phadema are sarcomas, gynecologic cancer, geni-
tourinary cancer and head and neck cancer, but the
most common malignancy to be associated with the
development o lymphedema is breast cancer, with
an incidence o 17% among survivors.
2. C. T e most common cause o secondary
lymphedema worldwide is Filariasis rom in ec-
tion by the nematode Wuchereria banchro i. In
developed nations, almost all cases o secondary
lymphedema are caused by a sequela o malignancy
or as a result o its treatment. Lymphedema praecox is
the most common orm o primary lymphedema and
accounts or around 94% o cases. T e onset is usually
seen in children and teenagers and is predominantly
C H AP TER 9 0 Ly m P H ATi C D i s EAs E 341
seen in women with a ratio o 10:1 compared to men.
Lymphedema tarda is an uncommon cause o pri-
mary lymphedema with an age o onset o 35 years
old or greater and accounts or less than 10% o cases.
3. D. Diagnosis o lymphedema is relatively simple
in the second and third stages o the disease. When
lymphedema is in the rst stage (i.e., pitting, mild,
and relieved by elevation) diagnosis can be more di -
cult. In patients with suspected secondary orms
o lymphedema, C scan and MRI are use ul in
excluding an underlying malignant etiology. In most
patients, the diagnosis o lymphedema can be made
based on a thorough history and physical exam
alone. Also, patients with previous known lymph
node excision, such as the patient in the vignette,
do not require additional studies or diagnosis o
lymphedema ( urther imaging is only necessary as
needed or ollow-up or each underlying malig-
nancy). In cases where the diagnosis o lymphedema
is suspected but the etiology is unclear, lymphoscin-
tigraphy is the diagnostic test o choice.
Lymphoscintigraphy has a sensitivity around 70%
to 90% and a speci city o nearly 100%. Lymphangi-
ography provides the best detail o the lymphatic sys-
tem, but due to complications such as lymphangitis,
pulmonary embolism, allergic reaction to the con-
trast dye and urther damage to the lymphatic ves-
sels, it is reserved or patients being considered or
lymphatic reconstruction.
4. C. T ere is no curative treatment or lymphedema.
T e goals o treatment are to minimize swelling and
prevent in ections to the a ected limb. Patients are
at increased risk o developing recurrent in ections
such as cellulitis, erysipelas and lymphangitis. A
combination o physical therapies (CP ) is the pri-
mary approach to the management o lymphedema.
CP involves good skin care ollowed by manual
lymphatic drainage through massage, bed rest with
leg elevation, application o graded compression
stockings and sequential pneumatic compression
devices. When worn daily, compression stockings
have shown long-term maintenance o reduced limb
circum erence, may protect against external trauma
and the development o skin and subcutaneous
tissue thickening.
No drug therapy or the treatment o lymphedema
has been shown to be e ective. Diuretics can be
342 G EN ERAL s U RG ERy EXAm i N ATi O N AN D BO ARD REVi EW
use ul in an acute exacerbation secondary to in ec-
tion or i seen with coexisting venous disease, but is
not use ul or long-term care o lymphedema. Cou-
marin is still under investigation as a potential treat-
ment or lymphedema, but currently has no role in
treatment in the United States.
Although patients with lymphedema are at
increased risk o developing recurrent in ections,
prophylactic use o antibiotics has no role in treat-
ment. Instead, patients should be prescribed antibi-
otics that they can keep with them and take at the
rst signs or symptoms o an in ection.
Patients with lymphedema can be managed non
operatively 95% o the time. Operative intervention
may be considered or patients with Stage II or Stage
III disease who have severe unctional disability. Sur-
gical intervention is made up o two categories: exci-
sional or reconstructive. Long-term ollow-up data
or surgical care o lymphedema is not available cur-
rently, and is there ore not well accepted as a main-
stay o treatment throughout the world.
5. B. T is clinical presentation is most concerning or
lymphangiosarcoma. Lymphangiosarcoma is a rare
malignant tumor that can occur in patients su ering
rom chronic lymphedema. T e tumor originates in
vascular endothelial cells and mani ests clinically as
a reddish-blue or purple skin lesion with a macular
shape, an ulcer, a poor healing eschar or a rm pain-
ul nodule.
Lymphangitis is usually caused by group A beta-
hemolytic streptococcal or staphylococcal in ections
and presents in an area o cellulitis. It clinically pre-
sents with pain and multiple linear, long, red streaks
toward the regional lymph nodes and can even man-
i est as a systemic response with evers, chills, sepsis,
or death. reatment consists o warm compresses
and intravenous antibiotics.
T rombophlebitis clinically presents with an ery-
thematous palpable cord along a super cial vein.
Causes o thrombophlebitis are rom an indwelling
catheter, venous stasis, intravenous drug use, or an
occult hypercoagulable state. reatment includes
compression stockings and anti-inf ammatory medi-
cations with surgery being reserved or clusters o
varicosities or cases o suppurative septic thrombo-
phlebitis.
BIBLIOGRAPHY
Burnand KG, McGuinness CL, lagattolla NR, et al. Value o
isotope lymphography in the diagnosis o lymphedema o
the leg. BR J Surg. 2002;89:748.
Cambria RA, Gloviczki P, Naessens JM, et al. Noninvasive
evaluation o the lymphatic system with lymphoscintig-
raphy: A prospective semiquantitative analysis in 386
extremities. J Vasc Surg. 1993;18:77382.
Cormier JN, Askew RL, Mungovan KS, et al. Lymphedema
beyond breast cancer: a systematic review and meta-
analysis o cancer-related secondary lymphedema. Cancer.
2010;116:5138.
Disipio , Rye S, Newman B, Hayes S. Incidence o unilateral
arm lymphoedema a er breast cancer: A systemic review
and meta-analysis. Lancet Oncol. 2013;14:500.
Freischlag JA, Heller JA. Venous disease. In: Beauchamp RD,
Evers BM, Mattox KL, et al. Sabiston extbook of Surgery:
T e Biological Basis of Modern Surgical Practice. 19th ed.
Philadelphia, PA: Elsevier Saunders; 2008: 2017.
Liem K, Moneta GL. Venous and lymphatic disease. In: Bru-
nicardi FC, Andersen DK, Billiar R, et al. Schwartzs Prin-
ciples of Surgery. 9th ed. New York City, NY: McGraw-Hill
Pro essional; 2009:147.
Marotel M, Cluzan R, Ghabboun S, et al. ransaxial computer
tomography o lower extremity lymphedema. Lymphology.
1998;31:1805.
Pipinos II, Baxter B . T e Lymphatics. In: Beauchamp RD,
Evers BM, Mattox KL, et al., eds. Sabiston extbook of Sur-
gery: T e Biological Basis of Modern Surgical Practice. 19th
ed. Philadelphia, PA: Elsevier Saunders; 2008: 202027.
Rockson SG. Lymphedema. Curr reat Options Cardivasc
Med. 2006;8:12936.
omita K, Yokogawa A, Oda Y, erahata S. Lymphangiosar-
coma in postmastectomy lymphedema (Stewart- reves
Syndrome): Ultrastructural and immunohistologic char-
acteristics. J Surg Oncol. 1988;38:275.
iwari A, Cheng KS, Button M, et al. Di erential diagnosis,
investigation, a current treatment o lower limb lymph-
edema. Arch Surg. 2003;138:15261.
Warren AG, Brorson H, Borud LJ, Slavin SA. Lymphedema:
A comprehensive review. Ann Plast Surg. October 2007;
59(4):46472.
Wake eld W, Rectenwald JR, Messina LM. Veins and Lym-
phatics. In: Doherty GM. Current Diagnosis and reatment
Surgery. 13th ed. New York, NY: McGraw-Hill Medical;
2009:804.
Werner G , Scheck R, Kaiserling E. Magnetic resonance
imaging o peripheral lymphedema. Lymphology. 1998;31:
3436.
Weissleder H, Weissleder R. Interstitial lymphangiography:
Initial clinical experience with a dimeric nonionic contrast
agent. Radiology. 1989;170:3714.
Yasuhara H, Shigematsu H, Muto . A study o the advan-
tages o elastic stockings or leg lymphedema. Int Angiol.
1996;15:272.
 91
Venous Stasis Disease
John illou
A 48-year-old emale presents with a 10-month his-
tory o le , lower extremity swelling with worsening
swelling and crampy pain over the last two days.
She has a history o hypertension or which she takes
hydrochlorothiazide. Her medical history is otherwise
unremarkable. She has no amily history o thrombo-
philia. On physical exam her distal pulses are easily
palpable. She is noted to have multiple bilateral lower
extremity varicosities as well as a brawny appearing,
well-granulated ulcer over the le medial malleolus.
T e circum erence o her le thigh is noted to be 5 cm
greater than that o the right thigh and her le cal is
4 cm greater in circum erence than that o the right
cal . C scan o the pelvis is consistent with May-
T urner Syndrome.
1. Which o the ollowing statements regarding May-
T urner Syndrome (M S) is true?
A. M S related thrombus accounts or 15% to 20%
o all lower extremity deep venous thromboses
(DV ).
B. Compression o the right common iliac vein by
the le common iliac artery is the most common
cause o M S.
C. A common cause o M S related mortality is
acute pulmonary embolism.
D. Duplex ultrasound is the best imaging modality
with which to assess or iliac thrombus.
E. In the setting o M S associated thrombosis,
anticoagulation alone is the most e ective rst
line treatment.
2. Which o the ollowing statements regarding
chronic venous insuf ciency (CVI) is true?
A. Venous stasis ulcers are o en located over the
lateral malleolus.
B. Ultrasound is o limited utility in the diagnosis
o venous insu ciency.
C. Distal extremity ulcerations associated with arte-
rial disease are twice as common as venous stasis
ulcers.
D. T e rendelenberg test can be used to distin-
guish between super cial and deep venous sys-
tem ref ux.
E. Cal muscle dys unction plays no role in venous
insu ciency.
3. Which o the ollowing is true regarding the
medical management o CVI?
A. Systemic antibiotics are recommended as part o
the routine treatment o venous stasis ulcers.
B. Hydrocolloid dressings have not been shown to
de nitively improve ulcer wound healing over
simple non-adherent dressings.
C. In terms o venous ulcer healing, inelastic
compression systems are more e ective than
multi-layer compression systems with an elastic
component.
D. Moderate exercise may limit venous ulcer wound
healing.
E. Intermittent pneumatic compression devices are
considered rst line treatment in the majority o
patients.
344 G EN ERAL S U RG ERY EXAM I N ATI O N AN D BO ARD REVI EW
4. Which o the ollowing is true regarding the
surgical management o CVI?
A. T e risk o greater saphenous nerve injury is
increased with greater saphenous vein stripping
distal to the knee.
B. Radio requency ablation o the greater saphe-
nous vein is not e ective at preventing long term
recurrence o venous ref ux.
C. umescent solution is not commonly used when
per orming endovenous laser ablation.
D. With regard to endovenous laser ablation, longer
laser wavelengths are better absorbed by hemo-
globin and there ore exert less o an ablative
e ect on the vein wall.
E. In the management o venous stasis ulcers,
allogra placement in conjunction with com-
pression has not been shown to improve wound
healing.
5. Which o the ollowing is true regarding varicose
veins?
A. Varicose veins are more prevalent in men than
women.
B. Liquid sclerotherapy is superior to oam in the
treatment o varicose veins in the setting o
greater saphenous vein ref ux.
C. Ischemic stroke has been reported as a complica-
tion o the use o oam sclerotherapy in the man-
agement o varicose veins.
D. Varicose veins are never pain ul.
E. T e use o compression stockings has been
de nitively ound to prevent the progression o
uncomplicated varicose veins.
ANSWERS
1. C. Causes o mortality in the acute setting include
pulmonary embolism and iliac vein rupture resulting
in a retroperitoneal hemorrhage. Individuals with
chronic M S may develop chronic le lower extrem-
ity edema as well as venous stasis ulcers. M S related
thrombosis accounts or 2% to 3% o lower extrem-
ity DV s and is most o en seen in emales 20 to
40 years old. Autopsy studies indicate that anatomic
eatures consistent with M S are ound in 22% to
32% o individuals in the general population.
M S is most commonly the result o compression
o the le common iliac vein by an overlying right
common iliac artery, although anatomic variants
involving compression o the in erior vena cava and
right common iliac vein do exist. Over time chronic
compression o the iliac vein leads to endothelial
injury and thrombus ormation. Acute M S related
thrombosis is o en heralded by the sudden onset
o le lower extremity pain and swelling and may
be precipitated by pregnancy or recent abdominal
surgery.
Duplex ultrasound lacks the sensitivity to detect
most cases o ileo emoral thrombus. T e pre erred
imaging modalities in cases o M S include C with
venous phase contrast or magnetic resonance (MR)
venogram.
Catheter directed thrombolyses as well as percu-
taneous mechanical thrombectomy with the addition
o endovascular stent placement are the treatments o
choice or the management o acute M S associated
thrombosis. Anticoagulation alone or with mechani-
cal thrombectomy without stent placement results in
re-thrombosis rates upwards o 70%. Endovascular
stent placement is also considered the rst line treat-
ment o M S without evidence o iliac thrombus.
2. D. T e rendelenberg test can be used to distinguish
between super cial and deep venous system incom-
petence. o per orm the test, the patient is placed in
the supine position and the a ected leg is elevated in
order to empty the super cial venous system. Either
manual compression or a tourniquet is applied
proximally and the patient is moved to an upright
position. Individuals with deep venous system insu -
ciency will have rapid lling o the super cial veins
whereas patients with ref ux that is limited to the
super cial venous system will not have lling or
greater than 20 seconds a er changing position.
Venous stasis ulcers are o en located over the
distal-medial aspect o the lower extremities, com-
monly in the vicinity o the medial malleolus. In con-
trast, ulcers associated with arterial disease tend to
occur over the distal digits or over distal-lateral bony
prominences. Both orms o ulceration can be pain-
ul. Venous stasis ulcers are typically shallow with
irregular boarders and commonly have a granulated
or brinous base.
Evaluation with duplex ultrasonography is recom-
mended or most patients with a new clinical diagno-
sis o venous insu ciency. Ultrasound is use ul in the
assessment o proximal venous compression, deep
vein thrombosis, and or determining the direction o
venous f ow. By using a rapid cu inf ation-def ation

maneuver while the patient is upright, the extent o
the reversal o venous f ow in the super cial system
can be determined. Reversal o f ow or greater that
0.5 seconds in duration is consistent with incompe-
tent super cial valves whereas reversal o f ow or
greater than one second is consistent with ref ux orig-
inating in the deep venous system.
Venous stasis ulcers are present in around 1% o
the population in westernized countries and account
or around 80% o lower extremity ulcers.
Normal cal muscle unction is thought to improve
venous return via a pump-like action during ambu-
lation and lower extremity exercise. Impaired cal
muscle unction has been shown to positively cor-
relate with the severity o venous insu ciency as well
as with the ormation o stasis ulcers.
3. B. A meta-analysis o 42 randomized trials compar-
ing the use o di erent dressing types in individuals
with venous stasis ulcers demonstrated no signi -
cant di erence in wound healing rates when using a
hydrocolloid dressing verses a simpler, less expensive
non-adherent dressing.
Bacterial colonization o stasis ulcers is common.
A meta-analysis that reviewed 22 trials involving the
use o topical antibiotics, antiseptics or systemic anti-
biotics ound no clear evidence to support the routine
use o systemic antibiotics in individuals with venous
stasis ulcers. T ere was some data to suggest the
use ulness o topical cadexomer iodine (not readily
available in the United States); however, the authors
concluded that more data was needed to deter-
mine the e cacy o alternative topical antibiotics/
antiseptics such as povidone iodine and mupirocin.
Systemic antibiotics are recommended in cases o
ulcers with surrounding cellulitis.
A recent Cochrane review ound that the use o
compressive dressings promotes increased ulcer
healing rates when compared to dressings without
an element o compression (i.e., Unna boot). Single
layer dressings were less e ective than multi-layered
dressings and multi-layered dressings utilizing an
elastic component were ound to be more e ective
than those without. Increased cal muscle unction as
the result o structured exercise is likely to improve
venous return and thereby promote ulcer healing.
Intermittent pneumatic compression devices are not
considered rst line treatment or most individuals with
chronic venous insu ciency as they are both expensive
and require patient immobilization while in use.
C H AP TER 9 1 VEN O U S S TAS I S D I S EAS E 345
4. A. T e classic greater saphenous vein (GSV) strip-
ping procedure involves stripping o the vein rom
the ankle to the groin with high ligation at the
sapheno- emoral junction. T e greater saphenous
nerve, which is a sensory cutaneous branch o the
emoral nerve, is at risk o injury as it emerges rom
the adductor canal ( ormed by the tendons o the
gracilis and sartorius muscles) to run with the GSV
just posterior-medial to the tibia. Injury to the nerve
results in loss o cutaneous sensation over the medial
leg and can be avoided by not stripping the GSV dis-
tal to the knee.
Radio requency ablation has been shown to result
in long term GSV occlusion with occlusion rates
upwards o 88% at our years in one large trial. Another
recent study reports GSV and small saphenous vein
occlusion rates o up to 94.6% and 94.5% respectively
at 14 months a er radio requency ablation.
umescent solution is used in both radio re-
quency ablation as well as endovenous laser ablation
to anesthetize the tissue surrounding the vein as well
as to protect the area rom thermal injury.
Shorter laser wavelengths are better absorbed by
hemoglobin whereas longer wavelengths are better
absorbed by water allowing them to have greater abla-
tive e ects on vein walls. Commonly used endovenous
laser wavelengths are between 810 and 1470 nm.
A Cochrane review rom 2013 ound that allo-
gra when used in conjunction with compression
resulted in superior healing o longstanding stasis
ulcers when compared to treatment with compres-
sion alone. O note, the authors concluded that cur-
rent data is insu cient to determine whether the use
o autogra or xenogra results in increased rates o
healing.
5. C. Although uncommon, ischemic strokes as well
as transient ischemic attacks have been reported
a er oam sclerotherapy. Additional complications
include DV , anaphylactic reactions, and local tissue
necrosis.
Varicose veins are approximately twice as com-
mon in women with a reported prevalence o 15% to
30.1% in men and 28% to 50.5% in women. Risk ac-
tors associated with the ormation o varicose veins
include prior pregnancy, standing occupations, prior
episodes o thrombophlebitis, DV , amily history,
and obesity.
Foam sclerotherapy, typically using 1% or 3%
polidocanol in a gas to liquid ratio o 4:1, has been
346 G EN ERAL S U RG ERY EXAM IN ATI O N AN D BO ARD REVIEW
ound to be superior to liquid polidocanol in the
treatment o varicose veins due to greater saphen-
ous vein ref ux. Lower extremity varicosities can be
pain ul with standing. In addition to cosmetic com-
plaints, patients requently report eelings o heavi-
ness, aching or itching sensations.
Despite numerous studies and randomized con-
trolled trials, compression stockings have not been
clearly shown to halt the progression or slow the
recurrence o uncomplicated varicose veins.
BIBLIOGRAPHY
Cavezzi A, Parsi K. Complications o oam sclerotherapy.
Phlebology. 2012;27(1):4651.
Choi JH, Park HC, Joh JH. T e occlusion rate and patterns
o saphenous vein a er radio requency ablation. J Korean
Surg Soc. 2013;84(2):10713.
Coleridge SP. Sclerotherapy and oam sclerotherapy or vari-
cose veins. Phlebology. 2009;24(6):2609.
Criqui MH, Jamosmos M, Fronek A, et al. Chronic venous
disease in an ethnically diverse population: the San Diego
Population Study. Am J Epidemiol. 2003;158(5):44856.
Evans CJ, Fowkes FG, Ruckley CV, Lee AJ. Prevalence o vari-
cose veins and chronic venous insu ciency in men and
women in the general population: Edinburgh vein study.
J Epidemiol Community Health. March 1999;53(3):14953.
Fernando RR, Koranne KP, Schneider D, Fuentes F. May-
T urner Syndrome. Texas Heart Institute Journal. 2013;
40(1):827.
Fretz V, Binkert CA. Compression o the in erior vena cava by
the right iliac artery: A rare variant o May-T urner syn-
drome. Cardiovasc Intervent Radiol. 2010;33(5):10603.
Gillespie DL, Writing Group III o the Paci c Vascular Sympo-
sium 6, Kistner B, et al.Venous ulcer diagnosis, treatment, and
prevention o recurrences. J Vasc Surg. 2010;52(5):8S14S.
Jones JE, Nelson EA, Al-Hity A. Skin gra ing or venous leg
ulcers. Cochrane Database Syst Rev. 2013;1: CD001737.
Kibbe MR, Ujiki M, Goodwin AL, et al. Iliac vein compres-
sion in an asymptomatic patient population. J Vasc Surg.
2004;39(5):93743.
Kim JY, Choi D, Guk Ko Y, et al. Percutaneous treatment o
deep vein thrombosis in May-T urner syndrome. Cardio-
vasc Intervent Radiol. 2006;29(4):5715.
Merchant RF, Pichot O, Myers KA. Four-year ollow-up on
endovascular radio requency obliteration o great saphe-
nous ref ux. Dermatol Surg. 2005;31(2):12934.
Molloy S, Jacob S, Buckenham , Khaw K , aylor RS. Arterial
compression o the right common iliac vein; An unusual
anatomical variant. Cardiovasc Surg. 2002;10(3):2912.
Nelson EA, Mani R, T omas K, Vowden K. Intermittent pneu-
matic compression or treating venous leg ulcers. Cochrane
Database Syst Rev. 2011;16(2): CD001899.
OMeara S, Cullum N, Nelson EA, Dumville JC. Compres-
sion or venous leg ulcers. Cochrane Database Syst Rev.
2012;14(11): CD000265.
OMeara S, Al-Kurdi D, Ologun Y, et al. Antibiotics and anti-
septics or venous leg ulcers. Cochrane Database Syst Rev.
2014;10(1):CD003557.
OSullivan GJ, Semba CP, Bittner CA, et al. Endovascular
management o iliac vein compression (May-T urner)
syndrome. J Vasc Interv Radiol. 2000;11(7):82336.
OSullivan GJ. T e role o interventional radiology in the
management o deep venous thrombosis: Advanced ther-
apy. Cardiovasc Intervent Radiol. 2011;34(3):44561.
Padberg F , Jr, Johnston MV, Sisto SA. Structured exercise
improves cal muscle pump unction in chronic venous
insu ciency: a randomized trial. J Vasc Surg. 2004;39(1):
7987.
Pal reyman SJ, Michaels JA. A systematic review o compres-
sion hosiery or uncomplicated varicose veins. Phlebology.
2009;24(1):1333.
Pal reyman S, Nelson EA, Michaels JA. Dressings or venous
leg ulcers: Systematic review and meta-analysis. BMJ.
2007;335(7613):244.
Rabe E, Otto J, Schliephake D, Pannier F. E cacy and sa ety
o great saphenous vein sclerotherapy using standardised
polidocanol oam (ESAF): A randomised controlled mul-
ticentre clinical trial. Eur J Vasc Endovasc Surg. February
2008;35(2):23845.
White-Chu EF, Conner-Kerr A. Overview o guidelines or
the prevention and treatment o venous leg ulcers: A U.S.
perspective. J Multidiscip Healthc. 2014;11(7):1117.
 92
T oracic Outlet Syndrome
Courtney E. Barrows
A 34-year-old emale nurse, previously healthy, pre-
sented to the emergency department with a 2-day his-
tory o right shoulder pain that came on suddenly when
she was li ing a heavy trash can. In addition, over the
past 24 hours she reports persistent right arm swelling
and bluish discoloration that is more severe with her
arm in the dependent position.
1. Which o the ollowing is true regarding the
pathophysiology o the condition this patient most
likely has?
A. Scalene muscle brosis is the major causative
actor.
B. It is due to compression o the subclavian artery,
most likely rom a cervical rib.
C. It is due to repeated compression o the subcla-
vian vein in the costoclavicular space, resulting
in intimal injury and thrombus ormation in the
axillary and subclavian veins.
D. Hypercoaguable state leading to spontaneous
subclavian vein thrombosis.
2. Which o the ollowing is the most common order
o anatomic structures in the thoracic outlet,
moving rom anteromedial to posterolateral?
A. Subclavius muscle, subclavian artery, subclavian
vein, phrenic nerve, anterior scalene muscle, bra-
chial plexus, middle scalene muscle.
B. Subclavius muscle, subclavian vein, phrenic
nerve, anterior scalene muscle, subclavian artery,
brachial plexus, middle scalene muscle.
C. Anterior scalene, subclavian vein, subclavius
muscle, subclavian artery, brachial plexus, mid-
dle scalene muscle, phrenic nerve.
D. Anterior scalene, subclavian vein, subclavius
muscle, brachial plexus, subclavian artery, mid-
dle scalene muscle, phrenic nerve.
3. Which o the ollowing is true with regards to the
diagnosis/workup o thoracic outlet syndrome?
A. Electromyography and nerve conduction tests
alone exhibit a strong degree o speci city in
diagnosing.
B. Scalene muscle injection are not help ul in diag-
nosing n OS but serve as a use ul temporizing
measure prior to de nitive surgery.
C. Venography is considered the gold standard or
the diagnosis o v OS, but the diagnosis can be
missed i the brachial veins are used or access.
D. In v OS, ndings on dynamic ultrasound scan
include presence o subclavian or axillary throm-
bus and decrease in venous velocity by 50% with
abduction.
4. Regarding the management o Paget-Schroetter
Syndrome, which o the ollowing is true?
A. Most patients can be managed with anticoagula-
tion alone and experience low recurrence rates.
B. It is best managed initially with angioplasty and
stenting prior to de nitive surgical decompres-
sion.
C. Catheter-directed thrombolysis ollowed by
irst rib resection is the pre erred management
strategy.
D. Primary patency rates exceed 90% i thrombol-
ysis is per ormed within 6 weeks o symptom
onset.
E. None o the above.
348 G EN ERAL S U RG ERY EXAM I N ATIO N AN D BO ARD REVI EW
5. Which o the ollowing is the most common
complication o a f rst rib resection?
A. lymphatic leakage
B. pneumothorax
C. intercostal brachial cutaneous nerve injury
D. long thoracic nerve injury
E. subclavian vein injury
ANSWERS
1. C. T e thoracic outlet is de ned as the anatomic
area bound by the clavicle superiorly, rst rib in e-
riorly, subclavius muscle anteriorly, and the middle
scalene muscle posteriorly. It is through this region
that the subclavian artery, vein, and brachial plexus
pass as they exit the chest. T e thoracic outlet syn-
drome ( OS) re ers to the compression o one or
more o the neurovascular structures as they exit
this region, can be subdivided into 3 major classes
depending upon the structure that is compressed (in
order o decreasing incidence): neurogenic, venous,
and arterial. Neurogenic OS (n OS) is by ar the
most common type, comprising greater than 90% o
all cases, and is due to compression o the brachial
plexus as it passes over the rst rib between the ante-
rior and middle scalene muscles (through the scalene
triangle).
Scalene muscle brosis as the result o a traumatic
event such as an MVC (classically whiplash injury)
or engaging in repetitive upper extremity activity
is a major causative actor, although occasionally
an anomalous rst rib or cervical rib can result in
n OS. T e most common presenting symptom is
arm paresthesias, present in approximately 90%
o patients. Other classical symptoms are pain and
weakness in the upper extremity, neck pain, and
occipital headaches. Pain and paresthesias are most
commonly noted in the C8- 1 (ulnar distribution).
Arterial OS (a OS) is the least common variant
with an incidence o approximately 1%. Patients
typically present with ispilateral hand and/or digit
ischemia rom distal embolization o a subclavian
artery stenosis or aneurysmal dilation, almost always
as a result o extrinsic compression rom a cervical or
anomalous rst rib. T e patient described above su -
ers rom venous OS (v OS), also known as Paget-
Schroetter Syndrome, which is thrombosis or severe
narrowing o the subclavian and/or axillary vein
rom chronic extrinsic compression at the level o the
costoclavicular space. It accounts or approximately
5% o all OS cases. It is classically seen in young,
healthy patients with a history o repetitive motion
(swimmers, baseball pitchers, manual laborer, nurse)
or those with an active li estyle. Symptoms include
arm swelling (unique to v OS), cyanosis, pain/
aching, and occasionally paresthesias in the ngers
or hands (o en secondary to hand swelling).
2. B. Moving rom anteromedial to posterolateral, the
subclavius muscle is the rst anatomic structure,
which attaches rom the rst rib to the in erior por-
tion o the clavicle and can be a source o compression
o the next structure, which is the subclavian vein. T e
phrenic nerve usually runs immediately posterior to
the subclavian vein along the anterior scalene muscle.
However, in approximately 5% to 7% o individuals it
can run anterior to the subclavian vein, and can be a
rare cause o subclavian vein compression.
T e subclavian artery is separated rom the vein
via the anterior scalene muscle. Posterior and lateral
to the artery are the brachial plexus and nally the
middle scalene muscle.
3. D. T e diagnosis o n OS can be challenging and is
made with a combination o physical examination
maneuvers as well as adjuncts such as nerve conduc-
tion studies, EMG, and even anterior scalene mus-
cle injections o local anesthetics or botox. T ere is
a growing body o evidence to suggest that anterior
scalene injections are reliable means to not only diag-
nose n OS but also predict which patients will ben-
e t rom surgical decompression. In one study, 122
patients being evaluated or n OS underwent ante-
rior scalene block using electrophysiologic guidance.
O the patients who were ultimately diagnosed with
a condition other than OS, only 5% had a positive
response to the block, compared to 92% o patients
with con rmed OS. In addition, o the patients who
underwent surgical decompression or OS, 94% o
patients with a positive response to scalene muscle
block preoperatively had success ul surgery while
only 50% o those with negative response preopera-
tively had good outcomes.
In addition to standard chest radiographs to
detect the presence o a cervical or anomalous rst
rib, dynamic duplex ultrasonography is used to iden-
ti y axillosubclavian thrombus as well as evaluate or
venous compression by having the patient abduct the
ipsilateral arm, which should result in a decrease in

venous velocity by 50%. Ultrasound is recommended
by the American College o Radiology as the best rst
approach or direct evaluation o arm veins, although
venography is still considered the gold standard or
making the diagnosis o v OS (Paget-Schroetter
Syndrome). However, ultrasound-guided access to the
deep system (true brachial veins) at the antecubital
ossa or upper arm is needed to obtain optimal visu-
alization and also per orm intervention. I the cephalic
vein is used or contrast injection, the diagnosis can
be missed.
4. D. Because o poor long-term outcomes with anti-
coagulation alone, which has been associated with
symptom recurrence in up to 70% o patients, the
standard accepted treatment or Paget-Schroetter
Syndrome is catheter-directed thrombolysis ollowed
by rst rib resection. However, success o thromboly-
sis decreases as the time between symptom onset and
presentation increases. Although the exact time rame
is up or debate, the best results have been achieved
in patients who present within 1014 days. Certainly
a er 6 weeks, long term patency results are quite low.
Angioplasty with or without venous stent is not
recommended as treatment or Paget Schroetter
Syndrome due to the rate o complications and re-
stensosis or thrombosis. Stenting o the vein run-
ning through the non-decompressed costoclavicular
junction has been shown to be complicated by stent
racture in some, de ormation in nearly all, and
rethrombosis rates as high as 40%.
5. B. All o the above have been reported as compli-
cations a er rst rib resection, with pneumothorax
being the most common.
Entry into the pleural space with resultant pneu-
mothorax and/or pleural ef usion is a known hazard
o rst rib resection. At the completion o the pro-
cedure, it is generally recommended to instill irriga-
tion into the eld and per orm a Valsalva maneuver
in order to check or pneumothorax. I present, a
small chest tube can be placed. In a large retrospec-
tive series o 770 patients who underwent supra-
clavicular rst rib resection and scalenectomy, very
ew operative complications were noted. Although
pneumothorax is a known complication o this pro-
cedure, no patients developed post operative pneu-
mothorax because or the 20% o patients in whom
the pleural space was inadvertently entered during
the procedure, a closed suction drain was placed to
C H AP TER 9 2 TH O RAC IC O U TLET S YN D RO M E 349
seal the de ect. Post operative causalgia requiring
sympathectomy occurred in two patients. One
patient experienced lymphatic leak.
In another series examining 334 surgeries or n OS,
13 complications (3.9%) occurred. T e most common
was pneumothorax (n = 7), or which 6 required chest
tubes and 1 patient required additional surgery. T ere
were 5 instances o vascular injury (4 minor subcla-
vian vein injuries and 1 transection o the internal
mammary artery resulting in a 2 L blood loss). T ere
was also one minor injury to the long thoracic nerve.
T e intercostal brachial nerve is encountered dur-
ing the transaxillary approach as it exits between the
1st and 2nd ribs, and should be preserved i possible.
Damage to this nerve would result in loss o sensa-
tion over the medial aspect o the arm.
BIBLIOGRAPHY
Adelman MA, Rosen RJ, et al. A multidisciplinary approach
to the treatment o Paget Schroetter syndrome. Ann Vasc
Surg. 1997;11:14954.
Altobelli GG, Kudo , Ahn SS, et al. T oracic outlet syndrome:
Pattern o clinical success a er operative decompression.
J Vasc Surg. 2005;42:1228.
Brooke BS, Freischlag JA. Contemporary management o tho-
racic outlet syndrome. Curr Opin Cardiol. 2010;25:53540.
Desai SS, Azizzadeh A, et al. Outcomes o surgical paracla-
vicular thoracic outlet decompression. Ann Vasc Surg.
2014;28:45764.
Doyle A, Saad WE, et al. Management o ef ort thrombosis
o the subclavian vein: todays treatment. Ann Vasc Surg.
2007;21:7239.
Hempel GK, Shutze WP, Anderson JF, Bukhari HI. 770 con-
secutive supraclavicular rst rib resections or thoracic
outlet syndrome. Ann Vasc Surg. 1996;10:45663.
Illig KA, Doyle AJ. A comprehensive review o Paget-Schroetter
syndrome. J Vasc Surg. 2010;51:153847.
Jordan SE, Machleder HI. Diagnosis o thoracic outlet syn-
drome using electrophysiologically guided anterior scalene
blocks. Ann Vasc Surg. 1998;12:2604.
Lee J , Karwowski JK, Olcott C, et al. Long-term thrombotic
recurrence a er nonoperative management o Paget-
Schroetter syndrome. J Vasc Surg. 2006;43:123643.
Meier GH, Pollack JS, Gusberg RJ, et al. Initial experience with
venous stents in exertional axillary-subclavian vein throm-
bosis. J Vasc Surg. 1996;24:97481.
Propper BW, Freischlag JA. T oracic Outlet Syndromes. In:
Cameron JL and Cameron AM. Current Surgical T erapy.
11th ed. Philadelphia, PA: Elsevier Saunders; 2014: 9247.
Sanders RJ, Hammond SL, Rao NM. Diagnosis o thoracic
outlet syndrome. J Vasc Surg. 2007;46:6014.
Sanders R. T oracic Outlet Syndrome: General Consider-
ations. In Cronenwett JL and Johnson KW, ed. Rutherfords
Vascular Surgery. 7th ed. Philadelphia, PA: Elsevier Saun-
ders; 2010:186577.
350 G EN ERAL S U RG ERY EXAM I N ATI O N AN D BO ARD REVI EW

Schroeder WE, Green FR. Phrenic nerve injuries: Report o a
case, anatomical and experimental researches, and critical
review o the literature. Am J Med Sci. 1902;123:196220.
Urschel HC, Patel AN. Surgery remains the most ef ective
treatment or Paget-Schroetter Syndrome: 50 yearsexperi-
ence. Ann T orac Surg. 2008;86:25460.
Urschel Jr HC, Razzuk MA. Paget-Schroetter Syndrome:
What is the best management? Ann T orac Surg. 2000;69:
16638.
Urschel HC, Patel AN. Paget-Schroetter syndrome therapy:
Failure o intravenous stents. Ann T orac Surg. 2003;75:
16936.
Gynec o l o gy a nd Obst et r ic s
Alan P. Gehrich
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 93
Ovarian Masses

Charles S. Dietrich III and Bradford P. Whitcomb

Disclaimer: T e views expressed in this manuscript are A. BRCA1 mutation

those o the authors and do not re ect the o cial policy B. BRCA2 mutation
or position o the Department o the Army, Department C. Lynch syndrome
o De ense, or the United States Government. D. Mother af ected with ovarian cancer
E. Mother and sister af ected with ovarian cancer
A 52-year-old post-menopausal emale presents to her
primary physician with abdominal bloating and uri- 3. For the above patient, what is the best management
nary requency over the past several weeks. She denies strategy?
abdominal or pelvic pain but con rms mild constipa-
A. Observation
tion with reported bowel movements every three days.
B. Percutaneous core biopsy o the adnexal mass
She has had no vaginal or rectal bleeding. Her past med-
C. Surgical exploration with staging and cytoreduc-
ical and surgical history is signi cant or mild hyper-
tion
tension and a prior cesarean delivery. Her mother was
D. Neoadjuvant chemotherapy
diagnosed with breast cancer at age 45.
E. Palliative care
On examination, her vital signs are normal. Abdomi-
nal exam reveals normal bowel sounds and mild dis- 4. Which of the following procedures should be
tention. No abdominal pain is elicited and there are no included in the surgical staging of an apparent
palpable abdominal masses. On pelvic exam, a nodular early ovarian malignancy?
mass is noted in the le adnexal region with decreased
A. Pelvic washings
mobility. Rectal exam is unremarkable. Laboratory
B. Removal o the ovarian mass
assessment shows a normal CEA, but her CA125 level is
C. Omentectomy
elevated at 430 U/mL.
D. Pelvic and para-aortic lymph node sampling
1. What is the best initial imaging study for a patient E. All o the above
with a suspected ovarian mass?
5. Which of the following adjuvant treatment options
A. Abdominal X-rays is associated with the greatest overall survival?
B. Ultrasound
C. Computerized tomography (C ) scan A. Intravenous cyclophosphamide and cisplatin
D. Magnetic resonance imaging (MRI) B. Intravenous paclitaxel and carboplatin
E. Positron emission tomography-computed C. Intravenous paclitaxel, carboplatin, and bevaci-
tomography (PE -C ) zumab
D. Intraperitoneal and intravenous paclitaxel and
2. Which of the following confers the highest risk for cisplatin
lifetime development of ovarian cancer? E. Intravenous cyclophosphamide and doxorubicin
354 G EN ERAL S U RG ERY EXAM I N ATI O N AN D BO ARD REVIEW
ANSWERS
1. B. T e best initial imaging study or evaluating an
ovarian mass is the trans-vaginal ultrasound ( VS).
Morphologic characteristics, volume o the mass,
and assessment o vascular resistance through color
Doppler assists in dif erentiating benign rom malig-
nant ovarian processes. T e addition o abdominal
ultrasound is important in delineating larger ovar-
ian and uterine masses extending outside the pelvis.
T e sensitivity o VS with color Doppler is approxi-
mately 92% to 99% or identi cation o malignant
tumors o the ovary. Findings on ultrasound sugges-
tive o a malignant process include complex masses
with solid and cystic components, internal or exter-
nal nodular excrescences, and surrounding pelvic
ascites (Figure 93-1). Although there is no universal
test or combination o tests that are recommended
or ovarian cancer screening, there is data to support
the use o the morphology index (based on tumor
characteristics and volume) derived rom VS nd-
ings to better risk strati y the ovarian abnormality as
benign versus malignant.
Plain lm X-rays are not very use ul in the evalu-
ation o ovarian masses as they are typically com-
posed o uid and so tissue; however, a plain lm
may reveal incidental calci cations, one o the hall-
mark ndings in ovarian teratomas. C per ormance
dif erentiating the so tissue structures within the
ovary is also limited. Radiation exposure and IV
contrast administration pose additional risk to the
patient. C is most use ul i malignancy is suspected
to evaluate or metastatic disease in the preoperative
Figure 93-1 A trans-vaginal ultrasound o an ovarian high
grade serous carcinoma demonstrating a complex mass with
solid and cystic regions.
planning phase. PE -C has poor sensitivity and
speci city or adnexal masses and is expensive. Its
utility is best served in a patient with a known ovar-
ian malignancy that has a suspicion o recurrence.
MRI is a rather speci c modality when investigating
the adnexa, and is usually reserved or indeterminate
ultrasound ndings.
2. A. Obtaining a thorough, and accurate, amily history
is mandatory in evaluating the patient with a suspi-
cious adnexal mass. T e average womens li etime risk
or developing ovarian cancer is 1.4%. However, in a
meta-analysis published in 1998, the li etime relative
risk o developing ovarian cancer with one af ected
rst degree relative was 3.1 (95% CI 2.63.7), con er-
ring a 5% li etime risk. I more than one relative was
af ected, the estimated relative risk increased to 11.7
(95% CI 5.325.9) (approximate 20% li etime risk).
Overall, approximately 5% to 10% o women diag-
nosed with ovarian cancer have an inherited syn-
drome that increases risk. BRCA1 and 2 are tumor
suppressor genes coding or a protein involved in the
repair o double-stranded DNA breaks. Mutations in
these genes are the most common deleterious amil-
ial mutations in ovarian cancer and con er the high-
est risk o penetrance compared to other risk actors.
Patients with BRCA1 mutations have a li etime ovar-
ian cancer risk o approximately 40% to 53%, while
BRCA2 penetrance is 20% to 30%. Hereditary Non-
Polyposis Colorectal Cancer (HNPCC), or Lynch
Syndrome, represents a de ect in the mismatch repair
(MMR) genes. T ese patients carry a very high risk
o developing colon and endometrial cancer, as well
as additional risk or other extracolonic malignan-
cies. Ovarian cancer risk varies based on the actual
genetic de ect: MLH1/MSH2424%; MSH6
111%; PMS26%. Other amilial syndromes, such
as Li-Fraumeni ( P53 mutation) and Peutz-Jeghers
(S K11 mutation) also carry increased risks o
developing ovarian cancer.
3. C. T e menopausal patient described has ndings
concerning or an ovarian malignancy based on her
constitutional symptoms, the adnexal mass, and her
elevated CA-125 level. In 2016, an estimated 22,280
new ovarian cancer cases will occur in the United
States, and there will be an estimated 14,240 deaths
(http://seer.cancer.gov/stat acts/html/ovary.html).
Ovarian cancer is the h leading cause or cancer
deaths among women. While symptoms occur in

women with ovarian malignancies, they are o en
vague and nonspeci c. As such, almost 80% o patients
are diagnosed with metastatic disease. Persistent
symptoms that should prompt evaluation o the
ovaries include pelvic pain, changes in bowel habits,
bloating, and urinary requency. T e overall 5-year
survival or all patients diagnosed with ovarian can-
cer is currently around 45%.
T e American College o Obstetricians and
Gynecologists (ACOG) and Society o Gynecologic
Oncology (SGO) recommend re erral o the meno-
pausal patient with an adnexal mass to a gyneco-
logic oncologist i any o the ollowing is ound: any
elevation in the CA-125, associated ascites, the mass
is xed or nodular, evidence o metastatic disease is
noted, or i amilial risk is determined. In the pre-
menopausal patient with an adnexal mass, re er-
ral should occur or CA-125 > 200 U/mL, ascites,
evidence o metastatic disease, or hereditary risk.
Observation has signi cant risk or delay in diagno-
sis and is not recommended. Percutaneous biopsy o
the mass carries signi cant risk or peritoneal seed-
ing or upstaging o the disease. Furthermore, it is not
accurate, with sensitivity or malignancy detection
ranging rom 25% to 82%.
Neoadjuvant chemotherapy (chemotherapy
given be ore surgical debulking o disease) is
another option or patients who have had a con r-
mation o ovarian cancer by paracentesis or other
biopsy. Patients with comorbid conditions making
them poor surgical candidates or those with bulky
upper abdominal or stage IV disease may bene t
most rom this approach. Recent trials have shown
that neoadjuvant chemotherapy of ers a signi cant
improvement in optimal cytoreduction at interval
surgery, diminished surgical morbidity, and similar
progression ree and overall survival rates in Stage
IIIC and IV ovarian cancer. However, there is much
debate internationally regarding this approach, and
up ront surgery remains the most common strategy
in the United States. Palliative care is an option once
a pathologic diagnosis and accurate stage or prog-
nosis has been determined, but it is usually reserved
or patients with progressive disease or or those with
signi cant comorbidities.
4. E. I an ovarian malignancy is con rmed on intra-
operative assessment, accurate staging is para-
mount to determine the extent o the disease and
appropriate adjuvant treatments. Upstaging o an
C H AP TER 9 3 O VARI AN MAS S ES 355
apparent malignancy con ned to the ovary ranges
rom 22% to 50% when ormal staging procedures
are per ormed. Formal staging usually includes the
ollowing: removal o the af ected ovary; removal o
the uterus and contralateral ovary (i ertility is not
desired); care ul evaluation o all peritoneal sur aces
with biopsy o any suspicious areas; peritoneal wash-
ings or cytologic evaluation; in racolic omentec-
tomy; random peritoneal sampling rom the right
hemidiaphragm, paracolic gutters, pelvic sidewalls,
bladder, and posterior cul-de-sac; and removal o
pelvic and para-aortic lymph nodes. Lymphadenec-
tomy probably is the most important and technically
challenging component o adequate staging. In a
review by Powless et al., 13% o apparent early stage
ovarian cancers were ound to have positive nodes.
While still recommended, several investigators have
questioned the utility o omentectomy and random
peritoneal biopsies when no gross disease is visible.
In their reviews, upstaging based on omentectomy
occurred in less than 4% o patients. Similarly, less
than 5% o patients were ound to have microscopic
disease on random peritoneal biopsies.
T e AC ION trial con rmed the importance o
adequate staging. In this study, patients with Stage IA
to IIA ovarian epithelial carcinoma were randomized
a er surgery to observation or adjuvant chemo-
therapy. Groups were urther strati ed into optimal
versus non-optimal staging categories. In a recent
long-term analysis, overall survival was improved in
patients with optimal surgical staging, even among
those receiving adjuvant chemotherapy [HR = 1.89,
p = 0.05]. Considerable debate is ongoing regarding
the route o surgical staging. Historically, laparotomy
was elt to of er the best exposure or ull evaluation
o all peritoneal sur aces, and this approach is still
standard today. However, as advances in minimally
invasive surgery have occurred in the past decade,
many investigators have concluded that operative
outcomes with a laparoscopic approach could be
compatible with those o laparotomy.
When an advanced ovarian malignancy is pre-
sent, the extent o surgical cytoreduction directly
correlates with overall survival. Cytoreduction is a
concept that has until recently been unique to the
management o ovarian malignancies. T e theoretic
bene ts o cytoreduction include improved patient
com ort, increased tumor per usion, increased
tumor growth raction, and improved immunologic
response. Removal o all individual tumor implants
356 G EN ERAL S U RG ERY EXAM IN ATIO N AN D BO ARD REVI EW
to less than one centimeter is currently considered
an optimal cytoreduction. However, the de nition o
optimal cytoreduction is rapidly changing, and most
gynecologic oncologists now consider reduction to
microscopic disease to be the goal. In a review o sev-
eral Gynecologic Oncology Groups (GOG) studies,
patients with Stage IIIC disease had an overall sur-
vival o 71.9 months when cytoreduction to micro-
scopic disease was achieved versus 42.4 months
when disease was reduced to < 1 cm. Achieving an
optimal cytoreductive status o en requires bowel
resection and extensive upper abdominal procedures
such as diaphragmatic stripping, splenectomy, and
distal pancreatectomy.
5. D. With the exception o Stage IA grade 1 tumors,
adjuvant chemotherapy is recommended or all epi-
thelial ovarian cancers ollowing surgical staging and
tumor cytoreduction. Platinum based therapy has
remained the cornerstone o therapy since the 1970s,
with the current standard incorporating paclitaxel
with carboplatin delivered intravenously every three
weeks or six to eight cycles. With platinum based
therapy, almost 75% o patients with advanced disease
will achieve remission. Un ortunately, recurrences are
likely, usually occurring within two years o primary
therapy, and are rarely curable. Intense ef orts are con-
tinually ongoing to discover novel treatment options.
Intraperitoneal (IP) chemotherapy has long inter-
ested gynecologic oncologists or its theoretic advan-
tages. However, due to the challenges in delivery and
increased toxicities, this route o administration was
not avored until recently. In 2006, GOG 172 dem-
onstrated one o the largest survival advantages or
any ovarian cancer study ever published. In this trial,
a 16 month overall survival advantage was ound or
an IP regimen (Day 1, intravenous paclitaxel; Day
2, intraperitoneal cisplatin; Day 8, intraperitoneal
paclitaxel) when compared to intravenous paclitaxel
and cisplatin delivered every three weeks. oxicities
were signi cantly increased in the IP group, with
most patients only completing an average o 4 out
o 6 planned cycles. However, quality o li e assess-
ments one year ollowing completion o therapy
were equivalent between the two groups. Following
this publication, the NCI issued a rare clinical alert
recommending that ovarian cancer patients be con-
sidered or IP treatment.
Only patients who achieve an optimal cytore-
ductive status are candidates or IP therapy, as
chemotherapy penetration into tumor nodules
exceeding one cm is diminished. IP ports can be
easily placed at the time o a cytoreductive surgery,
but this requires preoperative anticipation o nd-
ings and a lengthy discussion o adjuvant treatment
options. T e IP catheter can also be placed at a sec-
ond operation which can typically be accomplished
laparoscopically. A 9.6 French single lumen medport
is positioned over a rib in the midclavicular line near
the in erior costal margin. T e catheter is then tun-
neled subcutaneously to the level o the umbilicus
be ore entering the peritoneal cavity. Approximately
10 cm o catheter length should be contained intra-
abdominally. Port complications are the most likely
reason or discontinuation o therapy and include
in ection, catheter occlusion, and intestinal erosion.
Postoperative adhesions can also develop limiting
circulation o chemotherapy.
Signi cant ef orts are ocusing on biologic tar-
geted therapies in the treatment o ovarian cancer.
Bevacizumab, a monoclonal antibody that prevents
angiogenesis by inhibiting vascular endothelial
growth actor (VEGF), has received considerable
attention or its activity in a number o solid tumors.
Several studies using bevacizumab in combination
with cytotoxic chemotherapy have demonstrated a
progression- ree survival advantage in ovarian can-
cer; however, none have realized an overall survival
advantage to date.
BIBLIOGRAPHY
American College o Obstetricians and Gynecologists. ACOG
Practice Bulletin. Management o adnexal masses. Obstet
Gynecol. 2007;110(1):20114.
Anthoulakis C and Nikoloudis N. Pelvic MRI as the gold
standard in the subsequent evaluation o ultrasound-
intederminate adnexal lesions: a systematic review. Gynecol
Oncol. 2014;132(3):6618.
Armstrong DK, Bundy B, Wenzel L, et al. Intraperitoneal
cisplatin and paclitaxel in ovarian cancer. N Engl J Med.
2006;354(1):3443.
Burger RA, Brady MF, Bookman MA, et al. Incorporation o
bevacizumab in the primary treatment o ovarian cancer.
N Engl J Med. 2011;365(26):247383.
DePriest PD, Varner E, Powell J, et al. T e e cacy o a sono-
graphic morphology index in identi ying ovarian can-
cer: A multi-institutional investigation. Gynecol Oncol.
1994;55(2):1748.
Grabowski JP, Harter P, Buhrmann C, et al. Re-operation
outcome in patients re erred to a gynecologic oncology
center with presumed ovarian cancer FIGO I-IIIA a er
sub-standard initial surgery. Surg Oncol. 2012;21:315.

Harris RD, Javitt MC, Glanc P, et al. ACR Appropriateness
Criteria clinically suspected adnexal mass. Ultrasound Q.
2013;29(1):7986.
Kehoe S, Hook J, Nankivell M, et al. Chemotherapy or up ront
surgery or newly diagnosed advanced ovarian cancer:
Results rom the MRC CHORUS trial. J Clin Oncol. (Meet-
ing Abstracts.) 2013;31(15 suppl):5500.
Lee JY, Kim HS, Chung HH, et al. T e role o omentectomy
and random peritoneal biopsies as part o comprehensive
surgical staging in apparent early-stage epithelial ovarian
cancer. Ann Surg Oncol. 2014;21(8):27626.
National Comprehensive Cancer Network. Genetic/Familial
High-Risk Assessment: Colorectal (Version 1.2014). http://
www.nccn.org/pro essionals/physician_gls/pd / genetics_
colon.pd . Accessed May 14, 2014.
Ozols RF, Bundy BN, Greer BE, et al. Phase III trial o carbopl-
atin and paclitaxel compared with cisplatin and paclitaxel
in patients with optimally resected stage III ovarian can-
cer: A Gynecologic Oncology Group study. J Clin Oncol.
2003;21(17):3194200.
Park HJ, Kim DW, Yim GW, et al. Staging laparoscopy or the
management o early-stage ovarian cancer: A metaanalysis.
Am J Obstet Gynecol. 2013;209:58e18.
Perren J, Swart AM, P sterer J, et al. A phase 3 trial o beva-
cizumab in ovarian cancer. N Engl J Med. 2011;365(26):
248496.
C H AP TER 9 3 O VARI AN M AS S ES 357
Powless CA, Aletti GD, Bakkum-Gamez JN, et al. Risk actors
or lymph node metastasis in apparent early-stage epithe-
lial ovarian cancer: implications or surgical staging. Gyne-
col Oncol. 2011;122(3):53640.
Powless CA, Bakkum-Gamez JN, Aletti GD, et al. Random
peritoneal biopsies have limited value in staging o appar-
ent early stage epithelial ovarian cancer a er thorough
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Ramus SJ and Gayther SA. T e contribution o BRCA1 and
BRCA2 to ovarian cancer. Mol Oncol. 2009;3(2):13850.
Siegal R, Ma J, Zou Z, et al. Cancer statistics, 2014. CA Cancer
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Stratton JF, Pharoah P, Smith SK, et al. A systematic review and
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treatment o early ovarian cancer: long-term analysis rom
a randomized trial. J Natl Cancer Inst. 2010;102:9827.
Vergote I, rop CG, Amant F, et al. Neoadjuvant chemother-
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N Engl J Med. 2010;363(10):94353.
Young R, Decker D, Wharton J . Staging laparotomy in early
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 94
Ectopic Pregnancy

Charles S. Dietrich III and Brad ord P. Whitcomb

Disclaimer: T e views expressed in this manuscript are C. Computerized tomography (C ) scan

those o the authors and do not re ect the o cial policy D. Magnetic resonance imaging (MRI)
or position o the Department o the Army, Department E. Abdominal X-rays
o De ense, or the United States Government.
2. What single quantitative hCG level distinguishes
A 24-year-old emale presents to the emergency depart- between ectopic or intrauterine pregnancy
ment with worsening right pelvic pain over the past 12 (viable or nonviable) when no intrauterine uid
hours associated with vaginal spotting. She denies evers collection and normal adnexa are identif ed on
and chills and has had no nausea or vomiting. Her bowel ultrasonography?
movements have been regular, and she denies any urinary
A. 500 mIU/mL
symptoms. She is sexually active and not using contra-
B. 1000 mIU/mL
ception. Her last menstrual period was 7 weeks prior to
C. 2000 mIU/mL
presentation. Past medical and surgical history is remark-
D. 3000 mIU/ML
able only or a chlamydial in ection two years ago.
E. T ere is no single hCG value that can reliably
Her vital signs show a temperature o 98.6F with a
distinguish between ectopic or intrauterine
heart rate o 101 and blood pressure o 95/55. Focused
pregnancy.
examination shows mild abdominal distention with
right lower quadrant tenderness to deep palpation. No 3. Which o the ollowing is a contraindication to
peritoneal signs are elicited. Her pelvic exam reveals medically managing an ectopic pregnancy with
a small amount o bleeding rom a closed cervical os. methotrexate?
T ere is no cervical motion tenderness, but exquisite
A. Limited to no cardiac activity noted on ultraso-
tenderness with a slight ullness is appreciated in the
nography
right adnexal region.
B. Absence o pelvic pain
Laboratory assessment is notable or a positive urine
C. hCG = 4500 mIU/mL
hCG test. Quantitative hCG returns at 2200 mIU/mL.
D. Hemodynamically stable patient
Her white blood count is 6.5 109/L, hemoglobin
E. Unreliable ollow-up
9.8 g/dL, hematocrit 29.2%, and platelets are 230
109/L. Chemistries are unremarkable. 4. In a patient demonstrating hemodynamic
instability, what is the best management option or
1. What is the BEST initial imaging modality or this an ectopic pregnancy in the distal allopian tube?
patient? A. Expectant management
A. rans-vaginal ultrasound B. Methotrexate
B. rans-abdominal ultrasound C. Salpingostomy
 C H AP TER 9 4 EC To P i C P REg n An C y 359

D. Salpingectomy
E. Salpingo-oophorectomy

5. Once an ectopic pregnancy has been diagnosed,

what is the uture risk or another ectopic
pregnancy?
A. 1%
B. 10%
C. 20%
D. 50%
E. 75%

ANSWERS Figure 94-1 rans-vaginal ultrasound image o the uterus

demonstrating a thin endometrial lining with no intrauterine
1. A. When a women presents with pain and bleeding gestational sac.
in early pregnancy, the di erential diagnosis includes
a viable intrauterine pregnancy, a nonviable intrau- pregnancy when expected based on hCG levels and/
terine pregnancy, or an ectopic pregnancy. As ultra- or gestational age, identi cation o an adnexal mass
sound technology has improved, this modality, along adjacent to the uterus and medial to the ovary, and
with serum human chorionic gonadotropin (hCG) heterogeneous pelvic uid (Figures 94-1 and 94-2).
measurement, has become the cornerstone in the T e sensitivity o trans-vaginal ultrasound to detect
evaluation o early-pregnancy complications. Early ectopic pregnancy ranges rom 0.73 to 0.93 in
pregnancy development ollows a relatively predict- reported series.
able path as seen on trans-vaginal ultrasonography. A
gestational sac is rst seen around 5 weeks o gesta- 2. E. Human chorionic gonadotropic measurement
tional age when measured rom the beginning o the is the second diagnostic pillar in the evaluation o
last menstrual period. T e yolk sac then appears at early-pregnancy complications. Un ortunately, iso-
5 weeks. T e embryo can usually be visualized adja- lated hCG levels of en overlap the three most com-
cent to the yolk sac at approximately 6 weeks, and a vis- mon possibilities in patients with rst-trimester
ible heartbeat presents concurrently with the embryo bleeding: viable intrauterine pregnancies, nonviable
in most cases. Any deviations rom this expected intrauterine pregnancies, and ectopic gestations. A
pattern o development are worrisome or an abnor- single hCG value, there ore, cannot be used to reli-
mal gestation. Imaging studies with ionizing radia- ably di erentiate between these di erent possibilities
tion should be avoided in early pregnancy i possible. despite intensive e orts to determine a discrimi-
Furthermore, modalities such as C scan, abdominal natory level. As ultrasound capabilities improved,
X-rays, and MRI add little to the evaluation.
Review o managed care databases suggests that
ectopic pregnancies occur in 2.6% o all pregnan-
cies. Risk actors include a history o a prior ectopic
pregnancy, prior pelvic in ections, previous surger-
ies, and smoking. Six percent o maternal deaths
in early pregnancy are caused by ruptured ectopic
pregnancies. However, improved diagnostic modali-
ties which allow or earlier identi cation, have kept
the maternal case- atality rate low at 3.8 deaths per
10,000 ectopic pregnancies. While trans-abdominal
ultrasonography can identi y an intrauterine preg-
nancy, it lacks the capability to ully assess the adnexa.
Findings on trans-vaginal ultrasound suggestive o an Figure 94-2 rans-vaginal ultrasound image demonstrating
ectopic pregnancy include absence o an intrauterine an ectopic mass adjacent to the lef ovary (OV).
360 g En ERAL S U Rg ERy EXAM i n ATi o n An D Bo ARD REVi EW
previous investigators reported a high accuracy in
documenting an intrauterine gestation with hCG lev-
els between 1000 to 2000 mIU/mL. However, recent
studies have questioned these levels. Among women
with a pregnancy o unknown location and hCG lev-
els between 2000 to 3000 mIU/mL, 19 ectopic preg-
nancies and 38 nonviable intrauterine pregnancies
will be ound or each viable pregnancy, making the
likelihood o a viable pregnancy approximately 2%.
T e lower reliability o an hCG discriminatory zone
in the diagnosis o an intrauterine pregnancy may be
due to the higher rate o multiple gestations seen in
the obstetric population today. T e levels o hCG in
multiple gestations when compared to singleton preg-
nancies are higher or every stage o development.
In a patient with a pregnancy o unknown loca-
tion, obtaining at least one ollow-up hCG measure-
ment is recommended be ore initiating treatment to
avoid misdiagnosing a potential viable intrauterine
pregnancy. Ninety-nine percent o symptomatic
women with a viable pregnancy will demonstrate
at least a 53% increase in hCG levels over a 48 hour
interval. Serial evaluation should only be done i the
patient is hemodynamically stable and can be reli-
ably tracked.
3. C. Once an ectopic pregnancy has been con rmed,
there are our main treatment options: expectant
management, medical treatment with methotrexate,
conservative surgery with salpingostomy, and sal-
pingectomy. Categorizing the activity o the ectopic
pregnancy into very less active, less active, and active
can guide subsequent therapy. In general, less active
ectopic pregnancies can be managed medically with
high success rates. Active ectopic pregnancies usu-
ally require surgical intervention. Not surprisingly,
the de nition o activity has not been uni ormly
established. One author has proposed to de ne a less
active ectopic pregnancy (one that can be treated
with methotrexate) as one with a pretreatment hCG
< 5000, with no cardiac activity in the embryo, in
women with no symptoms, and in those who are
hemodynamically stable.
Methotrexate is an antimetabolite that inhibits
dihydro olate reductase. Proli erating tissues, includ-
ing trophoblastic cells, are readily a ected. Its use
in treating ectopic pregnancies was rst reported
in 1982 by anaka et al. While several regimens
are e ective, the most commonly used one today
is a single-dose regimen using 50 mg/m 2 injected
intramuscularly on Day 1. Serial hCG levels are
trended and a 15% decrease is expected between Day
4 and 7. Additional doses can be administered or ris-
ing or plateaued values. Reliable ollow-up is critical
when treating patients with methotrexate, and suc-
cess rates range rom 63% to 96.7% in the literature.
T is wide range is due to the many de nitions o suc-
cess and variations in patient characteristics.
4. D. Active ectopic pregnancies by de nition have
either ruptured or have impending rupture. Patients
can present with hemodynamic instability, hemop-
eritoneum, and associated severe pain. Surgical man-
agement is necessary or either patient stabilization
or because o the high ailure rate with a medical
approach. T e degree o hCG elevation usually is not
help ul in these cases as management is dictated by
the patients overall condition.
T e vast majority o ectopic pregnancies are
located in the distal allopian tube, accounting or
up to 97% o cases. Other ectopic implantation sites
include the interstitial portion o the allopian tube,
cervix, ovary, abdomen, and previous cesarean scar.
Heterotopic pregnancies (synchronous ectopic and
intrauterine pregnancies) are increasing in incidence
secondary to assisted reproductive technologies,
occurring in 1% to 3% o this population.
Surgical options or managing an ectopic in the
distal allopian tube include conservative salpin-
gostomy versus the more radical salpingectomy.
Both procedures are easible though a laparoscopic
approach, although patient stability and surgeon
experience will dictate the ultimate modality. Dur-
ing salpingostomy, a linear incision is made over
the antimesenteric bulging portion o the tube. A
suction irrigator is then used to hydrodissect and
remove the ectopic mass. T e tubal incision is not
reapproximated with suture and lef to close on its
own. Salpingectomy includes complete removal o
the allopian tube with the contained products o
conception.
T e choice between conservative salpingostomy
versus salpingectomy is usually made intraopera-
tively. Factors in uencing management include the
patients history (prior ectopic), patient pre erence,
the appearance o the contralateral tube, and bleed-
ing. In patients demonstrating hemodynamic insta-
bility, salpingectomy is usually pre erred and has a
100% e cacy rate. Salpingostomy carries a ailure
rate o 6.6% to 17.5%, leading to persistent ectopic

tissue in the pelvis. In these cases, the hCG level ails
to normalize, and subsequent treatment with metho-
trexate may be necessary.
5. B. T e rate o recurrent ectopic pregnancy ranges
rom 6% to 10% regardless o the treatment modal-
ity selected. Patients of en question their uture er-
tility chances af er having an ectopic pregnancy. T e
DEME ER trial compared medical management
with conservative salpingostomy, and ound no di -
erence in the 2-year ertility rate (67% vs. 71%, p =
0.37). T is trial also compared the 2-year ertility rate
between salpingostomy and salpingectomy and dem-
onstrated no di erence (70% vs. 64%, p = 0.78).
BIBLIOGRAPHY
Barnhart K , Sammel MD, Rinaudo PF, et al. Symptomatic
patients with an early viable intrauterine pregnancy: hCG
curves rede ned. Obstet Gynecol. 2004;104(1):505.
Benson CB, Doubilet PM, Peters HE, Frates MC. Intrauterine
uid with ectopic pregnancy: a reappraisal. J Ultrasound
Med. 2013;32:38993.
C H AP TER 9 4 EC To P i C P REg n An C y 361
Capmas P, Bouyer J, Fernandez H. reatment o ectopic preg-
nancies in 2014: new answers to some old questions. Fertil
Steril. 2014;101(3):61520.
Crochet JR, Bastian LA, Chireau MV. Does this woman have
an ectopic pregnancy? T e rational clinical examination
systematic review. JAMA. 2013;309(16):17229.
Doubilet PM, Benson CB, Bourne , Blaivas M. Diagnostic
criteria or nonviable pregnancy early in the rst trimester.
N Engl J Med. 2013;369:144351.
Doubilet PM, Benson CB. Further evidence against the reli-
ability o the human chorionic gonadotropin discrimina-
tory level. J Ultrasound Med. 2011;30:163742.
Fernandez H, Capmas P, Lucot JP, et al. Fertility af er ecto-
pic pregnancy: T e DEME ER randomized trial. Hum
Reprod. 2013;28:124753.
anaka , Hayashi H, Kutsuzawa , et al. reatment o intersti-
tial ectopic pregnancy with methotrexate: report o a suc-
cess ul case. Fertil Steril. 1982;37:8512.
Stovall G, Ling FW. Ectopic pregnancy: diagnostic and
therapeutic algorithms minimizing surgical intervention.
J Reprod Med. 1993; 38: 80712.
 95
Pelvic In ammatory Disease
Alan P. Gehrich
A 24-year-old gravida 0 caucasian emale with no sig-
ni cant medical or surgical history presents to the emer-
gency room with complaints o acute onset right lower
quadrant pain increasing over the preceding 24 hours.
She also endorses evers, nausea, and vomiting.
Her vital signs show a temperature o 100.8F, blood
pressure 113/67 with respirations 18 and pulse 85. Per-
tinent positives on physical exam include tenderness in
the right lower quadrant with voluntary guarding but
no rebound and hypoactive bowel sounds. Pelvic exam
reproduces exquisite right pelvic tenderness with a poorly
de ned pelvic mass. Laboratory evaluation includes a
negative HCG, WBC 15,000, hemoglobin and hematocrit
o 13 and 39 with platelet count o 350,000. She has nor-
mal renal and liver unction tests. Imaging studies show an
in ammatory mass in the right lower quadrant and pelvis.
1. Which o the ollowing bacteria is the most
common inciting organism in the development o
acute pelvic in ammatory disease?
A. Staphylococcus aureus
B. Gonorrhea
C. Escherishia Coli
D. Peptostreptococcus sp.
E. Bacteroides sp.
2. Which diagnostic radiologic study is the f rst line
imaging modality to evaluate or a gynecologic
pathology in this patient?
A. Computed tomography (C ) o the abdomen
and pelvis with contrast
B. rans-abdominal ultrasound
C. rans-vaginal ultrasound
D. Acute abdominal series
E. Magnetic resonance imaging (MRI) o the abdo-
men and pelvis with contrast
3. For the above patient, imaging documents a right
adnexal cystic structure 8 cm in greatest diameter
consistent with an abscess in the right adnexa. She
is admitted or treatment. Which o the ollowing
is the LEAST appropriate initial treatment option
or this patient?
A. Operative laparoscopy with drainage o the abscess
with intravenous ce otetan and doxycycline
B. Intravenous ce otetan plus doxycycline
C. Intramuscular ce riaxone and IV cipro oxacin
D. Intravenous ampicillin/sulbactam
E. C guided drainage with intravenous ce oxitin
and clindamycin
4. Further treatment is dependent on the patients
response to therapy. Which o the ollowing
statements is correct?
A. Sepsis is not commonly associated with a rup-
tured tubo-ovarian abscess but does not require
surgical intervention.
B. Bacteroides is the most requent cause o Gram-
negative sepsis associated with tubo-ovarian abscess.
C. Antibiotics should be switched rom paren-
teral to oral route o administration only a er
72 hours o clinical improvement, resolution o
nausea, vomiting, and severe pain.
D. I this patient does not respond to intravenous
antibiotics, a hysterectomy with bilateral sal-
pingo-oophorectomy is required or cure o a

tubo-ovarian abscess ( OA) resulting rom pel-
vic in ammatory disease.
E. T e most common sequelae o OA are in ertil-
ity, ectopic pregnancy, and chronic pelvic pain.
ANSWERS
1. B. Pelvic in ammatory disease (PID) is a polymi-
crobial ascending in ection that causes in ammation
o the upper genital tract, including endometritis, sal-
pingitis, pelvic peritonitis and in some cases leading
to OA ormation. T e general surgeon can be con-
sulted in cases in which an in ectious process involv-
ing the bowel such as diverticulitis or appendicitis, or
an extirpative surgery is being considered with severe
pelvic adhesive disease involving the bowel. T e gen-
eral surgeons expertise may be required in the sur-
gical drainage o a OA, or to assist in managing a
patient suf ering rom li e threatening sepsis arising
rom a suspected OA.
PID is diagnosed in more than 800,000 women
annually in the United States. Ninety percent o these
in ections are treated as outpatients. T e vast majority
o cases are ound in the reproductive age emale less
than 25 years o age. Many cases o PID, however, are
asymptomatic and there ore elude diagnosis. PID typ-
ically originates with an in ection o either Chlamydia
trachomatis or Neisseria gonorrheoea in the lower uro-
genital tract. T ese pathogens ascend the genital tract
causing cervicitis, endometritis and salpingitis. With
the accompanying damage to the lower genital tract,
bacterial organisms, generally ound in the perianal
region, can ascend through the cervix. As a result, PID
trans orms into a poly-microbial in ection which may
ultimately mani est as a OA and sepsis. Occasionally,
patients with chlamydia in ection develop perihepati-
tis (Fitzhugh-Curtis Syndrome), an in ammation o
the liver capsule and adjacent peritoneal sur aces.
Anaerobic and acultative aerobic bacteria, with
or without N. gonorrheae and C. trachomatis, have
been isolated rom the upper genital tract o women
with PID. OAs are caused by endothelial damage
and associated edema within the allopian tube. T e
intrinsic de ense mechanisms o the upper genital
tract become compromised leading to rapid bacte-
rial growth. As the in ection progresses, the ovary
becomes involved with invasion o the ovarian
epithelium. Classically peritonitis is characterized
by brinoid exudate on the serosal sur aces o the
uterus, tubes, and ovaries leading to agglutination.
C H AP TER 9 5 P El v i C i n f l Am m ATo Ry D i s EAs E 363
T is brinoid exudate can be seen laparoscopically
on any intra-abdominal organ extending to the liver
edge. Necrosis inside the complex in ammatory
mass may lead to one or more polymicrobial abscess
cavities. Interestingly, C. trachomatis has never been
isolated rom an abscess cavity.
Classic symptoms or PID include abdominal
pain, abnormal discharge, inter-menstrual or post-
coital bleeding, ever, urinary urgency, low back pain,
nausea, and vomiting. Symptoms o OA can be
indistinguishable rom acute salpingitis and appen-
dicitis. OAs generally mani est with symptoms to
include abdominal and pelvic pain (> 90%), ever
(50%), vaginal discharge (28%), nausea (26%), and
abnormal vaginal bleeding (21%). wenty percent o
OA cases, however, have normal white blood cell
counts. T ere is no single complaint, physical exam
nding or laboratory nding that is highly sensitive
or speci c or the diagnosis o PID, and the clinical
diagnosis o PID has a positive predictive value o
only 65% to 90%.
2. C. T e diagnosis o OA requires the nding o
an in ammatory mass on exam or imaging. rans-
vaginal ultrasound is considered the rst-line imag-
ing modality or gynecologic pathology, because it
provides excellent imaging o the upper genital tract,
is relatively inexpensive and does not expose the
patient to radiation. C scan o the abdomen/pelvis
with contrast is pre erred in cases where the diagno-
sis is uncertain, and in which there is a concern or a
coexisting malignancy or gastrointestinal pathology
such as appendicitis or diverticulitis. T e C scan has
increased sensitivity to detect a OA (78% to 100%
vs. 75% to 82%) and improved speci city (100% vs.
91%) as compared to ultrasound. MRI has limited
utility in the evaluation o acute pelvic pain.
3. D. reatment choice or OA is dependent on many
actors. At a minimum, all patients with OA require
admission and treatment with intravenous antibi-
otics. Multiple regimens are considered acceptable
and should be implemented based on the resistance
pro le in the community. T ese regimens must pro-
vide broad coverage or not only N. Gonorrheae and
C. trichomatis, but also or Mycoplasma genitalium,
Gram positive, and Gram negative acultative aer-
obes, as well as anaerobic organisms (see able 95-1).
T e cephalosporin based regimens are pre-
erred due to improved tolerability. Clindamycin,
364 G En ERAl s U RG ERy EXAm i n ATi o n An D Bo ARD REv i EW
Table 95 1 INPATIENT PARENTERAL ANTIBIOTIC
REGIMENS FOR TREATMENT
OF SEVERE PELVIC INFLAMMATORY DISEASE
AND TUBO-OVARIAN ABSCESS
Recommended Regimen:
Clindamycin 900 mg intravenously every 8 hours
PLUS
Ce riaxone 1 g intravenously every 12 hours
Substitute gentamicin or ce riaxone in patients with
Beta-lactam allergy: gentamicin loading dose 2 mg/kg
intravenously or intramuscularly ollowed by
maintenance dose (1.5 mg/kg) every 8 hours. Single
daily dosing may be substituted.
Alternative Regimens:
Ce oxitin 2 g intravenously every 6 hours
OR
Ce otetan 2 g intravenously every 12 hours
PLUS
Doxycycline 100 mg intravenously or orallya every
12 hours
OR
Ampicillin/sulbactam 3 g intravenously every 6 hours
PLUS
Doxycycline 100 mg orally or intravenouslya every
12 hours
a
May be initiated when patient is able to tolerate oral therapy to avoid
phlebitis associated with parenteral doxycycline.
Source: Soper DE. Pelvic in ammatory disease. Obstet Gynecol.
2010;116:419428.
metronidazole and ce oxitin have been shown to have
superior abscess wall penetration and activity within
the cavity in animal models. Amnioglycosides have
reduced activity in acidic, anaerobic environments
such as those ound in abscesses. Adding ampicillin
to gentamicin and clindamycin nearly doubles cure
rates or OA rom 47% to 87.5%. Due to the high
rates o resistance o E. Coli, ampicillin-sulbactam
is no longer recommended as a single agent or the
treatment o community acquired intra-abdominal
in ections. T e resistance o community acquired
N. Gonorrheae to uoroquinolones has also elimi-
nated this class o antibiotics as a rst or second line
treatment option or PID or OA. Antibiotic therapy
can be switched rom a parenteral to an oral route
o administration a er 24 to 48 hours o clinical
improvement including resolution o nausea and
vomiting, evers, and severe pain. Patients should
complete a 14 day course with oral antibiotics. T ese
regimens include doxycycline (100 mg BID) com-
bined with metronidazole (500 mg BID). Other regi-
mens include amoxicillin/clavulante (875 to 2000 mg
BID) or trimethoprim/sul amethaxazole (800/160 mg
BID) and metronidazole (500 mg BID). Drainage is
not necessary as a rst line treatment unless there is
concern or sepsis, which would indicate a ruptured
abscess.
4. E. When clinical response is not achieved within
48 hours a er initiation o antibiotics, surgical man-
agement or drainage should be strongly considered.
When drainage o a OA is indicated, options include
a percutaneous approach by interventional radiology,
or a surgical approach via either a laparoscopic or
open procedure. Unilateral salpingo-oophorectomy
may also be necessary depending on the clinical
scenario. Pelvic abscesses have been drained using
ultrasound or C guidance with a transabdominal,
transgluteal, transrectal, or transvaginal approaches
depending on the location o the abscess with suc-
cess rates o 77.8 to 100%.
T e decision or surgical management o a OA
with either drainage or excision depends on the sta-
tus o the patient and the size o the abscess. When
rupture is suspected based on presentation with acute
abdomen or septic shock, prompt surgical interven-
tion is required because o the high morbidity and
risk o mortality associated with a ruptured OA. E.
Coli is the most common isolate in women with rup-
tured OAs and a requent cause o Gram-negative
sepsis. Large case series have shown that antimicro-
bial therapy alone is usually ef ective in 70% o all
OAs and, in a ew o these studies, abscess size has
been shown to be predictive o treatment success
with antibiotics alone. Reed et al. showed that 35% o
abscesses 7 to 9 cm in size required surgery as com-
pared to almost 60% o abscess > 9 cm. DeWitt et al.
showed that abscesses > 8 cm more o en required
drainage or surgery. It is reasonable to observe the
ef ect o IV antibiotic therapy without immediate
surgery in women who are not developing signs o
sepsis and whose abscess is 8 cm or less in diameter.
When clinical response is not achieved with
antibiotic therapy, surgical management should be
considered. Hysterectomy with bilateral-salpingo-
oophorectomy is generally not necessary but can be
considered i patient has extensive disease and has

completed child-bearing. A post-menopausal patient
with a OA should be consented or total abdominal
hysterectomy with bilateral salpingo-oophorectomy
due to the strong association with either gynecologic
or intestinal malignancy. Hysterectomy with bilateral
salpingo-oophorectomy has the least risk o recur-
rence but also the highest surgical morbidity. T e
long-term sequelae o PID are in ertility or ectopic
pregnancy due to tubal scarring and chronic pelvic
pain attributed to pelvic adhesive disease.
BIBLIOGRAPHY
Boardman LA, Peipert JF, Brody JM, Cooper AS, Sung J. Endo-
vaginal sonography or the diagnosis o upper genital tract
in ection. Obstet Gynecol. 1997;90(1):547.
Chappell CA, Wiesen eld HC. Pathogenesis, diagnosis, and
management o severe pelvic in ammatory disease and
tuboovarian abscess. Clin Obstet Gynecol. 2012;55(4):893
903.
Dewitt J, Reining A, Allsworth JE, Peipert JF. uboovarian
abscesses: Is size associated with duration o hospitaliza-
tion and complications? Obstet Gynecol Int. 2010;2010:
Article ID 847041.
Gaitan H, Angel E, Diaz R, Parada A, Sanchez L, Vargas C.
Accuracy o ve dif erent diagnostic techniques in mild-
to-moderate pelvic in ammatory disease. Infect Dis Obstet
Gynecol. 2002;10(4):17180.
Granberg S, Gjelland K, Ekerhovd E. T e management o
pelvic abscess. Best Pract Res Clin Obstet Gynaecol. 2009;
23(5):66778.
Horrow MM. Ultrasound o pelvic in ammatory disease.
Ultrasound Q. 2004;20(4):1719.
Hiller N, Sella , Lev-Sagi A, Fields S, Lieberman S. Computed
tomographic eatures o tuboovarian abscess. J Reprod
Med. 2005;50(3):2038.
C H AP TER 9 5 P El v i C i n f l Am m ATo Ry D i s EAs E 365
Jaiyeoba O, Soper DE. A practical approach to the diagnosis
o pelvic in ammatory disease. Infect Dis Obstet Gynecol.
2011;2011: Article ID 753037.
Joiner KA, Lowe BR, Dzink JL, Bartlett JG. Antibiotic levels in
in ected and sterile subcutaneous abscesses in mice. J Infect
Dis. 1981;143(3):48794.
Landers DV, Sweet RL. ubo-ovarian abscess: Contemporary
approach to management. Rev Infect Dis. 1983;5(5):87684.
McNeeley SG, Hendrix SL, Mazzoni MM, Kmak DC, Ran-
som SB. Medically sound, cost-ef ective treatment or pel-
vic in ammatory disease and tuboovarian abscess. Am J
Obstet Gynecol. 1998;178(6):12728.
Mingeot-Leclercq MP, Glupczynski Y, ulkens PM. Amino-
glycosides: Activity and resistance. Antimicrob Agents Che-
mother. 1999;43(4):72737.
Patton DL, Moore DE, Spadoni LR, Soules MR, Halbert SA,
Wang SP. A comparison o the allopian tubes response to
overt and silent salpingitis. Obstet Gynecol. 1989;73(4):622
30.
Reed SD, Landers DV, Sweet RL. Antibiotic treatment o tubo-
ovarian abscess: Comparison o broad-spectrum beta-
lactam agents versus clindamycin-containing regimens.
Am J Obstet Gynecol. 1991;164(6 Pt 1):155661; discussion
15612.
Soper DE. Early recognition o serious in ections in obstetrics
and gynecology. Clin Obstet Gynecol. 2012;55(4):85863.
Soper DE. Pelvic in ammatory disease. Obstet Gynecol. 2010;
116(2 Pt 1):41928.
Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and
management o complicated intra-abdominal in ection in
adults and children: Guidelines by the surgical in ection
society and the in ectious diseases society o America. Surg
Infect (Larchmt). 2010;11(1):79109.
Sutton MY, Sternberg M, Zaidi A, St Louis ME, Markowitz LE.
rends in pelvic in ammatory disease hospital discharges
and ambulatory visits, united states, 1985-2001. Sex Transm
Dis. 2005;32(12):77884.
 96
Endometriosis

Alan P. Gehrich

A 26-year-old gravida 0 emale with history o chronic A. Endometriosis presents with a uni orm type o
low grade right pelvic pain presents to the emergency lesion.
room with onset o acute right lower quadrant pain over B. T e number and size o the lesions directly cor-
the course o the preceding 12 hours. T e gynecology relates with patient symptoms.
team has taken patient to the operating room to address C. Endometriosis is commonly ound outside o the
her pain with the preliminary diagnosis o ruptured pelvis.
ovarian cyst. On diagnostic evaluation, they nd severe D. Deep endometriotic lesions can become retro-
endometriosis with a large right sided endometrioma peritonealized and be di cult to appreciate lapa-
involving the appendix. T e ovary with endometrioma roscopically.
is xed to the right pelvic side wall and posterior uterus. E. Endometriosis is not associated with in ertility.
Endometriosis has completely obliterated the posterior
cul-de-sac with thick adhesions between the recto- 4. An oophorectomy plus appendectomy is
sigmoid colon and the uterus. T e gynecology service performed in the above patient. If this patient
has requested assistance rom the general surgery ser- has persistent pain post operatively consistent
vice to extricate the ovary and per orm appendectomy. with endometriosis, which therapy would be least
appropriate?
1. Which of the following is the LEAS common
A. GnRH (gonadotropin releasing hormone) ago-
symptom for endometriosis?
nist therapy
A. Dyschezia B. Oral contraceptive therapy
B. Dyspareunia C. Medroxy-progesterone acetate intramuscular
C. In ertility injection therapy
D. Dysmenorrhea D. Le oophorectomy
E. Hematochezia E. Non-steroidal anti-in ammatory therapy
2. T e most common site of intestinal endometri-
osis is: 5. If endometriosis involves the recto-vaginal septum
or bowel, which of the following statements is
A. Rectum and sigmoid
correct?
B. Appendix
C. Cecum A. Colonoscopy or rigid proctoscopy are o high
D. Small bowel yield in diagnosing bowel endometriosis.
B. ransvaginal ultrasound has a < 50% sensitivity
3. Which of the following statements is true concern- and speci city in diagnosing recto-vaginal endo-
ing the laparoscopic evaluation of endometriosis? metriosis.

C. Gross endometriotic lesions along the appendix
and small bowel are common.
D. Excision o recto-vaginal endometriosis
improves ertility.
E. Pain outcomes with bowel resection o endo-
metriosis are similar to those with rectal nodule
excision without bowel resection.
ANSWERS
1. E. T e dif erential diagnosis or acute as well as
chronic pelvic pain is broad involving the gyneco-
logical, urologic, gastrointestinal, musculoskeletal,
and neurologic systems. Most commonly the general
surgeon is consulted in cases o acute pelvic pain in
cases in which a gastrointestinal diagnosis such as
appendicitis, diverticulitis, or hernia is entertained.
However, as in the above scenario, the general sur-
geon may also be consulted to assist in the treatment
o chronic pelvic pain with endometriosis generally
due to severe adhesive disease involving the bowel.
Endometriosis af ects 6% to 10% o reproductive-
aged women. T e most common presentations
include dysmenorrhea (79%), generalized pelvic
pain (69%), and dyspareunia (45%). Bowel symp-
toms such as constipation, diarrhea, dyschezia, and
tenesmus are present in up to 36% o patients with
severe endometriosis. Hematochezia originating
rom endometriosis is rare.
2. A. Endometriosis is de ned as hormonally respon-
sive endometrial tissue ound outside o the uterus. It
is ound most commonly on the ovary, uterine serosa,
in the posterior cul-de-sac along the uterosacral liga-
ments, and in the ovarian ossae, but can be ound
throughout the peritoneal cavity. Cases o lesions in
the thorax presenting as catamenial pneumothorax
and in central nervous system have also been reported.
Rectovaginal or intestinal involvement is estimated to
be present in 5% to 12% o women with endometrio-
sis. Intestinal endometriosis involves the rectum and
sigmoid colon in 76% o cases, the appendix in 18%
and the cecum in 5%. Small bowel is rarely involved.
3. D. Laparoscopy is considered the gold standard
or the diagnosis o endometriosis with visual iden-
ti cation o endometriotic lesions. T ree histologic
subtypes o endometriotic lesions are ound in the
peritoneal cavity: super cial lesions, deep in ltrative
lesions (DIE), and endometriomas. Endometriotic
C H AP TER 9 6 En d o m ETRi o s i s 367
lesions are highly variable in size, texture, and color.
Endometriosis can present as brotic scar tissue,
hemorrhagic or clear vesicles, at yellow-brown
lesions or the classic raised reddish-blue islands
which are typically ound on the peritoneal lining
o the pelvis. Although visual inspection by an expe-
rienced surgeon can have sensitivity o 94% to 97%
and speci city o 77% to 85%, histopathologic con-
rmation remains the standard or diagnosis. Inter-
estingly, neither the severity nor location o disease
correlates directly with the severity o symptoms.
Super cial lesions can cause pain symptoms, how-
ever are rarely associated with adhesions. In contrast,
deep in ltrative endometriosis lesions invade into
neighboring tissue leading to signi cant pelvic adhe-
sive disease which can involve bowel and bladder
such as depicted in the above scenario. In rare cases
this invasion is transmural leading to endometriosis
in the lumen o the bladder or bowel with associ-
ated cyclic hematuria, dysuria, hematochezia, or dys-
chezia. Endometriotic lesions, particularly DIE, can
become reperitonealized making it di cult to appre-
ciate the extent o the lesions when observing them
laparoscopically.
Endometriomas are accumulations o ectopic
endometrial tissue on the ovary and have character-
istic ultrasound ndings. Although endometriosis is
associated with in ertility, the impact o endometrio-
mas on reproductive unction is uncertain. Multiple
large, prospective studies demonstrate that asympto-
matic endometriomas do not negatively impact the
live birth rates associated with assisted reproductive
technologies. However, according to most studies,
excision o endometriomas may result in a deleteri-
ous impact on surrogate markers o ovarian reserve.
T us, endometrioma excision may be associated with
a worse prognosis or uture reproductive interven-
tions compared to medical management or obser-
vation. However, this distinction, is probably only
critical with emale patients older than 35 years o age.
4. D. Endometriosis can be treated both medically
and surgically. A patients desire or uture ertility
and the magnitude o her symptoms will help deter-
mine the primary mode o therapy. Medical therapy
is either analgesic or hormonal. All orms o hormo-
nal birth control have been shown to be ef ective in
suppressing endometriosis-associated pain. T ese
include oral contraceptive pills, patches, rings, inject-
able or implantable progestins, or the levonorgestrel
368 G En ERAL s U RG ERY EXAm i n ATi o n An d Bo ARd REVi EW
intrauterine device. T ese modalities prevent the
cyclic stimulation o the endometriosis tissue by
either inhibiting ovulation or by local endocrine
ef ect. Second line therapy involves gonadotropin
releasing hormone agonist (GnRH) which eliminates
the pulsatile GnRH signals o the hypothalamus on
the pituitary. T is process suppresses gonadotropin
secretion rom the pituitary which in turn mark-
edly decreases production o gonadal steroids by the
ovary. A potential complication o long term unop-
posed therapy with a GnRH agonists is a reduction
in bone mineral density.
T e goal o surgery is to extirpate as much o the
endometriosis as possible while reestablishing nor-
mal pelvic anatomy. T e risks and bene ts o aggres-
sive surgical treatment or endometriosis need to be
care ully weighed. T e de nitive surgery or endo-
metriosis involves the complete removal o all endo-
metriosis lesions as well as the uterus and ovaries. In
a patient with severe, symptomatic endometriosis
who has completed child-bearing, a hysterectomy
with bilateral oophorectomy should be considered.
T e treatment or the patient with uture ertility
desires have to be individualized. T e most recent
large scale review in the Cochrane database does not
demonstrate that endometriosis cysts have a delete-
rious ef ect on pregnancy or live birth rates. T us,
surgical treatment o an endometrioma should be
reserved or those patients who are symptomatic or
have ndings concerning or cancer.
Recommended treatment involves either excision
o the cyst wall or unilateral oophorectomy, both o
which generally improve symptoms and lower risk
o symptomatic recurrence as compared to simple
drainage and electrocoagulation. Most patients with
symptomatic endometriosis, who wish to maintain
their ovaries, bene t rom post-operative hormonal
suppression in the treatment o chronic pelvic pain.
5. E. T e general surgeon will most likely be involved
in endometriosis surgery with bowel involvement as
depicted in the above scenario. Colonoscopy is o low
value in diagnosing rectovaginal endometriosis as
endometriotic lesions may invade through the serosa
into the muscularis, but rarely into the bowel lumen.
Based on a meta-analysis by Hudelist involving 1100
patients, trans-vaginal ultrasound has a sensitiv-
ity o 91% and a speci city o 98% or rectovaginal
endometriosis. Magnetic resonance imaging (MRI)
and barium enema may also be used preoperatively
with reasonable accuracy in making diagnosis. Gross
endometriotic lesions along the appendix are rare
but i ound should prompt appendectomy. Decision
on the type o surgery or deeply invasive recto-vag-
inal endometriosis should be decided on a case-
by-case basis. Bowel resection has been reported in
numerous trials with improvement o 70% o pain
symptoms however all report complications. Pain
outcomes rom rectal nodule excision without seg-
mental bowel resection seem to be similar with less
associated post-operative complications.
BIBLIOGRAPHY
Benschop L, Farquhar C, van der Poel N, Heineman MJ. Inter-
ventions or women with endometrioma prior to assisted
reproductive technology. Cochrane Database Syst Rev.
2010;(11):CD008571. doi(11):CD008571.
Berker B, Hsu HS, Lee KL, Nezhat C, Nezhat F, Nezhat C.
Section 10.3 laparoscopic treatment o endometriosis. In:
Nezhat C, Nezhat F, Nezhat C, eds. Nezhats operative gyne-
cologic laparoscopy and hysteroscopy. 3rd ed. Cambridge
University Press; 2008:263303.
Duepree HJ, Senagore AJ, Delaney CP, Marcello PW, Brady
KM, Falcone . Laparoscopic resection o deep pelvic
endometriosis with rectosigmoid involvement. J Am Coll
Surg. 2002;195(6):7548.
Falcone , Lebovic DI. Clinical management o endometrio-
sis. Obstet Gynecol. 2011;118(3):691705.
Giudice LC, Kao LC. Endometriosis. Lancet. 2004;364(9447):
178999.
Hudelist G, Ballard K, English J, et al. ransvaginal sonogra-
phy versus clinical examination in the preoperative diag-
nosis o deep in ltrating endometriosis. Ultrasound Obstet
Gynecol. 2011;37(4):4807.
Leone Roberti Maggiore U, Scala C, Venturini PL, Remorgida
V, Ferrero S. Endometriotic ovarian cysts do not negatively
af ect the rate o spontaneous ovulation. Hum Reprod.
2015;30(2):299307.
Ra F, Metwally M, Amer S. T e impact o excision o ovar-
ian endometrioma on ovarian reserve: A systematic review
and meta-analysis. J Clin Endocrinol Metab. 2012;97(9):
314654.
Roman H, Vassilief M, Gourcerol G, et al. Surgical manage-
ment o deep in ltrating endometriosis o the rectum:
Pleading or a symptom-guided approach. Hum Reprod.
2011;26(2):27481.
Sinaii N, Plumb K, Cotton L, et al. Dif erences in character-
istics among 1000 women with endometriosis based on
extent o disease. Fertil Steril. 2008;89(3):53845.
Walter AJ, Hentz JG, Magtibay PM, Cornella JL, Magrina JF.
Endometriosis: Correlation between histologic and visual
ndings at laparoscopy. Am J Obstet Gynecol. 2001;184(7):
140711; discussion 14113.
Wolthuis AM, omassetti C. Multidisciplinary laparoscopic
treatment or bowel endometriosis. Best Pract Res Clin
Gastroenterol. 2014;28(1):5367.
Neur o sur g er y
Matthew J. Martin
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 97
Back Pain/Sciatica
Albert Schuette
A 53-year-old emale presents to the emergency room
with the acute onset o le leg pain while walking her dog.
T e patient did not all at the time o presentation nor is
there a history o recent trauma. T e pain starts in the
le buttock and radiates down the le leg to the posterior
cal and oot. T e patient also describes some numbness
in the le cal and mild plantar- exion weakness. She
gives a past medical history o well-controlled hyperten-
sion and does not smoke cigarettes. A er the emergency
room physician provides some pain relie in the orm o
narcotics, a consult to the surgical team is made.
1. When a physician is evaluating a patient with signs
and symptoms o sciatica, what would be picked
up in the history and physical that would alert the
physician o a more emergent disease process?
A. Acute onset o urinary or bladder and bowel
incontinence with saddle anesthesia
B. Steroid use
C. Immunosuppression
D. IV drug use
E. All o the above
2. A er the history and physical are completed, what
should the initial imaging be in the emergency
room with the radicular pain and mild numbness
and no history o trauma as described in the
question stem?
A. Magnetic resonance imaging (MRI) o the lum-
bar spine without gadolinium in the emergency
room
B. Computerized tomography scan (C ) without
contrast o the lumbar spine
C. C myelogram o the lumbar spine
D. No imaging in the acute setting in the absence
o signs o cancer, racture, or cauda equina syn-
drome
E. Plain PA and lateral X-ray o the lumbar spine
3. T e patient is seen in clinic 2 weeks a er the
initial presentation to the emergency room. She
continues to have severe pain in the le leg with
a positive straight leg raise and a decreased ankle
jerk. An MRI has been completed, which shows
a disc herniation at L5-S1 impinging on the le
S1 nerve root. What is the typical next step in
management o the patients sciatica?
A. In orm the patient o the risks and bene ts o
surgery and schedule her or a discectomy at
L5-S1.
B. In orm her that 85% o patients improve with-
out surgery within the rst 6 weeks and give her
more time to recover.
C. Recommend activity modi cation with bed rest
or 1 to 2 weeks.
D. Prescribe oral steroids to reduce the in amma-
tion around the nerve root.
E. Recommend antidepressant therapy as there is a
psychological component to sciatica that should
be treated.
4. Which o the ollowing acts concerning the
anatomy and prevalence o lumbar herniated discs
is true?
A. L4-5 and L5-S1 account or about 50% o herni-
ated lumbar discs.
372 G EN ERAL S U RG ERY EXAM I N ATIO N AN D BO ARD REVI EW
B. T e nerve root involved in a typical lateral recess
herniated disc between L4-L5 is the nerve root
that exits at the higher level (L4).
C. T e nerve root involved in an extreme lateral
herniated disc between L4-L5 is the nerve root
that exits at the lower level (L5).
D. Cauda equina syndrome rom a herniated lum-
bar disc accounts or only 1% to 2% o lumbar
disc surgeries.
E. Herniated lumbar discs in the pediatric age
group are quite common but in requently require
surgery.
5. T e patient undergoes an unevent ul micro-
discectomy or her L5-S1 herniated disc. A er
surgery her strength is noted to be intact in
bilateral lower extremities throughout all muscle
groups. T e night o surgery the patient complains
o severe back pain, new weakness in her le
plantar- exion and urinary retention. What is the
most likely cause o these new symptoms?
A. Reherniation o a disc ragment at the operative
level
B. In ammation o the nerve root rom surgery
C. Spinal epidural hematoma
D. Damage o the nerve root rom retraction at the
time o surgery
E. Unintended durotomy causing arachnoiditis
ANSWERS
1. E. T is is an extremely important question in evalu-
ating a patient with back pain and radiculopathy. T e
physician must know the red ag symptoms that
would alert him/her as to a more severe process. All
o the answers in this section provide a clue to those
syndromes. Answer A, acute onset o urinary or blad-
der and bowel incontinence with saddle anesthesia,
re ers to cauda equina syndrome (CES). T ough
there is controversy as to whether the patient should
go to surgery within 24 or 48 hours, it remains a sur-
gically urgent case. Answer B, steroid use, could put a
patient at risk or both an in ectious or a minor trau-
matic process. Answer C, immunosuppression, puts
the patient at risk or an in ectious process such as
osteomyelitis or epidural abscess. Finally, answer D,
IV drug use, would also put the patient at high risk
or epidural abscess or osteomyelitis.
2. D. T is can be a di cult answer to arrive at or sur-
geons. In most cases, patients come to the clinic with
a diagnosis and imaging already included with them.
When the patient rst comes to the ER on symptom
onset, the correct answer is No imaging in the f rst
month o symptoms. T is remains true only in the
absence o the red ag symptoms discussed as these
red ags aid the physician in ruling out cancer, in ec-
tion, spinal racture, and cauda equina syndrome.
Some red ags that should tip of a surgeon to a pos-
sible malignancy are a history o cancer (the most
predictive), age over 50, unexplained weight loss, and
a ailure to improve a er 1 month. Possible malig-
nancies include primary tumors such as osteoblas-
toma, osteosarcoma, and lymphoproli erative tumors
and metastatic bone disease rom lung, thyroid, pros-
tate, kidney and colon cancer among others. I pain
persists, MRI is generally the imaging modality o
choice per ormed without gadolinium. In patients
with a contraindication or an MRI (pacemakers,
etc.), a C myelogram can provide adequate visuali-
zation.
3. B. T e patient in the question stem is only 2 weeks
out rom onset o pain. Barring a neurologic de -
cit or signs o cauda equina syndrome, patients are
given time to recover rom the herniation. Over 85%
o herniated disc patients will improve without sur-
gical intervention in approximately 6 weeks. Bed rest
is an option or 2 to 3 days maximum in patients with
radicular complaints, as more time can be harm ul
or recovery. Additionally, antidepressants are more
indicated or chronic back pain and oral steroids
have not been shown to improve symptoms.
4. D. T is question addresses the prevalence and
anatomy o herniated discs in the lumbar spine.
L4-5 and L5-S1 account or over 90% o herniated
lumbar discs. When examining the lumbar spine,
the nerve root that exits between L4 and L5 is the
L4 root. Most discs herniate into the lateral recess,
which is medial to the exiting nerve root. In this way,
the disc impinges on the nerve root on deck (see
Figure 97-1). T is is an image o a L5-S1 disc hernia-
tion. T e vertical arrow indicates the disc herniation
in the lateral recess compressing the S1 nerve root.
T e horizontal arrow indicates the L5 nerve root in
the neuro oramen.
An L4-5 disc herniation in the lateral recess would
cause pain in an L5 distribution. An extreme lateral
disc at L4-5, on the other hand, would impinge on
the exiting nerve root, L4. It is important to realize

Figure 97-1 L5-S1 disc herniation: the vertical arrow indi-
cates disc herniation in the lateral recess compressing the S1
nerve root. T e horizontal arrow indicates the L5 nerve root
in the neuro oramen.
that cauda equina syndrome is uncommon account-
ing or only 1% to 2% o all herniated disc surger-
ies. Also, herniated lumbar discs in the pediatric age
group are quite rare as stated.
5. C. When per orming or providing care or a patient
who underwent a discectomy, it is extremely impor-
tant to per orm thorough neurologic tests. Compli-
cations associated with a discectomy can include a
reherniation o the disc (up to 4% over 10 years),
temporary worsening o motor unction (1% to 8% o
patients3), and unintended durotomy (0% to 14% o
cases). All o these may be a cause o temporary wors-
ening neurologic unction. Any new neurologic de -
cit in a patient ollowing surgery should be assumed
to be a spinal epidural hematoma until proven oth-
erwise. Work-up should include an immediate MRI
and return to the operating room. Long-term com-
plications o microdiscectomy are uncommon and
C H AP TER 9 7 BAC k PAI N / S C I ATI C A 373
are o en related to reherniation or instability in the
spinal segment. T ese complications can present
with recurrence o the patients leg pain, pain in the
back or buttocks, and weakness/ numbness in the dis-
tribution o the compressed nerve root.
BIBLIOGRAPHY
Allen C, Glasziou P, Del Mar C. Bed rest: A potentially harm-
ul treatment needing more care ul evaluation. Lancet.
October 9, 1999;354(9186):122933.
Chau AM, Xu LL, Pelzer NR, Gragnaniello C. iming o
surgical intervention in cauda equina syndrome: A sys-
tematic critical review. World neurosurgery. March-April
2014;81(3-4):64050.
Davis RA. A long-term outcome analysis o 984 surgically
treated herniated lumbar discs. Journal of neurosurgery.
March 1994;80(3):41521.
Deyo RA, Rainville J, Kent DL. What can the history and
physical examination tell us about low back pain? JAMA.
August 12, 1992;268(6):7605.
Downie A, Williams CM, Henschke N, et al. Red ags to screen
or malignancy and racture in patients with low back pain:
systematic review. Bmj. 2013;347: 7095.
Ebersold MJ, Quast LM, Bianco AJ, Jr. Results o lumbar dis-
cectomy in the pediatric patient. Journal of neurosurgery.
November 1987;67(5):6437.
Fager CA. Observations on spontaneous recovery rom inter-
vertebral disc herniation. Surgical neurology. October
1994;42(4):2826.
Graves JM, Fulton-Kehoe D, Jarvik JG, Franklin GM. Early
imaging or acute low back pain: One-year health and dis-
ability outcomes among Washington State workers. Spine.
August 15, 2012;37(18):161727.
Greenberg MS, ed. Handbook of Neurosurgery. 7th ed. New
York, NY: T ieme Medical Publishers; 2010.
Henschke N, Maher CG, Ostelo RW, de Vet HC, Macaskill P,
Irwig L. Red ags to screen or malignancy in patients
with low-back pain. T e Cochrane database of systematic
reviews. 2013;2:CD008686.
Hodges SD, Humphreys SC, Eck JC, Covington LA. Man-
agement o incidental durotomy without mandatory bed
rest. A retrospective review o 20 cases. Spine. October 1,
1999;24(19):20624.
Webster BS, Bauer AZ, Choi Y, Ci uentes M, Pransky GS. Iat-
rogenic consequences o early magnetic resonance imag-
ing in acute, work-related, disabling low back pain. Spine.
October 15, 2013;38(22):193946.
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Or t h o pedic Sur ger y
Matthew J. Martin
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 98
Calcaneus Fractures

Justin T. Fowler and Justin Robbins

A 27-year-old pro essional painter sustained a all rom C. Non-contrast computerized tomography (C )
a een oot sca old while on the job. By his report, scan with reconstructions
he landed on both eet in a standing position and had D. riple phase bone scan
immediate severe oot and leg pain and was unable to E. None o the above. Adequate in ormation is pro-
ambulate. His primary survey is unremarkable and his vided by the radiographs.
secondary survey is normal except or the examination
o his right oot. He presents to the emergency depart-
ment with a swollen and de ormed right oot and com-
plains o severe pain at rest and with any palpation
or manipulation o the oot. Radiographs o the right
oot reveal a comminuted, intra-articular calcaneus
racture.

1. Plain radiographs o the patients right oot

are shown (Figure 98-1). What other associated
injury is classically described rom this type o
mechanism ( all rom height landing on both eet)
and associated with the presence o this injury?
A. Closed head injury
B. Hollow viscous injury
C. Pelvic racture
D. Lumbar spine racture
E. Concomitant oot ractures

2. Anteroposterior, lateral, and oblique radiographs

are per ormed and reveal a displaced calcaneus
racture. What other imaging modality should be
ordered to urther delineate the injury?
Figure 98-1 Lateral oot radiograph revealing a displaced,
A. Non-contrast magnetic resonance imaging intra-articular calcaneus racture with depression o the
(MRI) posterior acet. Radiographs courtesy o MAJ Justin Fowler
B. Weight-bearing oot lms MD.
378 G EN ERAL S U RG ERY EXAM I N ATI O N AN D BO ARD REVI EW

3. Several hours have gone by while awaiting urther
work up and disposition o the patient and you
notice that the skin overlying the Achilles tendon
is becoming dark and appears to be tented by the
racture. What is the next most appropriate course
o action?
A. Emergent reduction in the emergency room
B. Emergent orthopaedic consultation
2. C. Initial diagnosis o a calcaneus racture can be
C. Placement o a well-padded splint and strict
elevation
D. C angiography o the lower extremity
E. Emergent compartment pressure check o the
oot
4. What is the pre erred treatment or a displaced,
intra-articular racture o this bone in a young,
active patient?
A. Well-padded splint with conversion to a short
leg cast
B. Closed reduction and casting
C. Percutaneous screw xation
D. Emergent open reduction internal xation
E. Delayed open reduction internal xation
5. Which o the ollowing is predictive o a better
outcome a er open reduction and internal f xation
o a displaced, intra-articular racture o this type?
A. Female gender
B. Signi cant articular impaction
C. Workers compensation
D. Age > 50
E. Heavy laborer
T e other injuries listed can occur with any signi -
cant trauma mechanism, but are all less commonly
associated with calcaneus and other ractures o the
oot. Any patient with this type o mechanism should
be suspected o having a lumbar spine racture until
proven otherwise, and the optimal diagnostic study
is a dedicated C scan o the lumbar spine.
readily made with conventional plain X-rays o the
oot (Figure 98-1). T e simplest broad classi cation
o calcaneus ractures is based on whether there is
articular involvement, with 75% o ractures being
intra-articular, and approximately 25% being extra-
articular. Although the initial diagnosis can o en
be made with standard X-rays, a high-quality C
o the hind oot is the de nitive imaging modality
o choice or diagnosis, classi cation, and operative
planning. T e C scan should be per ormed with 2
to 3 mm interval slices in the sagittal, axial, and 30
degree semi-coronal planes (Figure 98-2). T is imag-
ing modality allows or accurate characterization o
the racture pattern and acilitates planning or the
patients de nitive treatment. A C scan is use ul in
assessing the amount and location o joint impaction,
lateral wall blowout, involvement o calcaneocuboid
joint, and the number o primary racture lines in the
posterior acet. An MRI has little additional utility
compared to a high-quality C scan or diagnosing,
characterizing, or directing treatment plans or cal-
caneus ractures. Similarly, additional X-rays includ-
ing weight-bearing lms will not provide su cient

ANSWERS
1. D. T is patient has a calcaneus racture. T e associ-
ated injuries, speci cally lumbar spine injuries, have
been historically reported in up to 50% o patients.
T e most common mechanism o injury or calca-
neus ractures has been a all rom a height with the
patient initially striking the ground with their eet
in a standing or semi-standing position. T is results
in the calcaneus racture, but also the transmis-
sion o impact orces up the spine, with the lumbar
region bearing most o the burden. As motor vehi-
cle collisions have become an increasingly prevalent
mechanism, newer data has suggested that roughly
10% o patients with calcaneus racture will have a
concomitant lumbar spine injury and approximately Figure 98-2 Coronal C scan showing the articular involve-
25% have other additional lower extremity injuries. ment o this impacted calcaneus racture.

anatomic details, and will also likely be poorly toler-
ated by the patient with a calcaneus racture.
3. B. Displaced avulsion ractures o the posterior
tuberosity with impending skin necrosis require
immediate reduction to prevent ull thickness skin
loss over the posterior ankle and Achilles tendon.
Emergent orthopaedic surgical consultation should
be obtained as closed reduction typically is not
adequate to remove tension rom the skin. T is is
typically treated as an orthopaedic emergency and
usually requires surgical reduction and stabilization
in the operating room in an acute ashion.
T e ankle can be splinted in plantar-f exion in
an attempt to take pressure o the overlying skin
while awaiting surgical consultation. Placement o a
splint will not provide any bene t, and in act could
produce additional pressure necrosis on the area i
not tted well or i there is additional swelling a er
the splint is placed. C angiography is only use ul i
there is a suspicion o a concomitant vascular injury
in the ractured extremity, and has no role or evalu-
ation o oot ractures with a normal vascular exam.
Emergent compartment pressures are indicated i
there is suspicion o a compartment syndrome, but
in this scenario the primary problem is the displaced
racture and not an elevated compartment pressure.
4. E. Intra-articular displacement o the calcaneus has
been shown to lead to subtalar arthrosis, sub bular
impingement, di culty with shoe wear, hind oot
sti ness, and limited unction. I the articular sur ace
is amenable to reconstruction in a young, healthy
patient, then surgical xation should be attempted.
T e status o the so tissue envelope dictates the tim-
ing o surgical intervention. raditionally, delayed x-
ation through an extensile lateral approach has been
the mainstay treatment or these ractures. T ese
patients will typically have a signi cant amount o
swelling, bruising, and so tissue edema o the oot
which can result in poor wound healing i surgery is
per ormed during the acute phase. Open reduction
and internal xation is typically delayed to allow this
so tissue swelling to subside and mitigate the risk o
C H AP TER 9 8 C ALC AN EU S F RAC TU RES 379
surgical site complications, poor wound healing, so
tissue loss, and hardware in ections.
5. A. A prospective, randomized, controlled trial o
non-operatively treated versus operatively treated
calcaneus ractures rom our Canadian trauma
centers revealed that certain patient demograph-
ics were predictive o better versus worse outcomes
a er treatment o displaced intra-articular calcaneus
ractures. Women treated with operative xation had
signi cantly higher quality o li e scores than women
who were managed non-operatively. T e study also
showed that heavy laborers, workers compensation
cases, older age, higher degree o articular commi-
nution, and smoking are all predictors o worse out-
comes a er operative xation. T e exact reason or
this gender disparity remains unknown, but these
actors should be taken into consideration when plan-
ning a management strategy and in counseling the
patient regarding the risks versus bene ts o operative
versus non-operative management.
BIBLIOGRAPHY
Benirschke SK, Kramer PA. Wound healing complications
in closed and open calcaneal ractures. J Orthop Trauma.
2004;18(1):16.
Buckley R, ough S, McCormack R, Pate G, Leighton R, Pet-
rie D, Galpin R. Operative compared with non-operative
treatment o displaced intra-articular calcaneal ractures:
a prospective, randomized, controlled multicenter trial.
J Bone Joint Surg Am. 2002;84(10):173344.
Buckley RE, ough S. Displaced intra-articular calcaneal rac-
tures. J Am Acad Orthop Surg. 2004;12(3):1728.
Cave EF. Fracture o the oscalcisthe problem in general. Clin
Orthop Relat Res. 1963;30:646.
Gilmer PW, Herzenberg J, Frank JL, Silverman P, Martinez S,
Goldner JL. Computerized tomographic analysis o acute
calcaneal ractures. Foot Ankle. February 1986;6(4):18493.
Koski A, Kuokkanen H, ukiainen E. Postoperative wound
complications a er internal xation o closed calcaneal
ractures: a retrospective analysis o 126 consecutive
patients with 148 ractures. Scand J Surg. 2005;94(3):2435.
Protheroe K. Avulsion ractures o the calcaneus. J Bone and
Joint Surg Br. 1969;51(1):11822.
Sanders RW, Clare MP. Fractures o the Calcaneus. Surgery of the
Foot and Ankle. Philadelphia, PA: Mosby; 2007: 20172075.
 99
Shoulder rauma

Kelly G. Kilcoyne

A 24-year-old male presents as an acute trauma a er C. Femur racture

injury in a motorcycle crash. On initial presentation D. Arterial injury
he is a GCS 11 (E3V3M5). Because o severe pain and E. Brachial plexus injury
labored breathing, he is intubated and sedated. During
your secondary survey, you note the patient has sig- 4. Upon further clinical evaluation you note that
ni cant edema, swelling, and abrasions about the right the patient has a prominence along the anterior
shoulder girdle. aspect of his shoulder and a sulcus adjacent to
the posterior acromion. He is still not following
1. What serious, and potentially devastating, commands, but examination with gentle range
diagnosis is characterized by lateral displacement of motion demonstrates limitations in internal
of the scapula? rotation and abduction. What is your next step in
A. Pnuemothorax management?
B. Multiple rib ractures A. Attempt a closed reduction.
C. Scapulothoracic dissociation B. Obtain a chest C .
D. Shoulder dislocation C. Schedule an outpatient magnetic resonance
E. Sternoclavicular dislocation image (MRI).
D. Obtain orthogonal X-rays.
2. What study can you evaluate or obtain to further E. Diagnosis should be made based on physical
investigate and diagnose the suspected injury in exam.
Question 1?
A. Ventilationper usion (VQ) scan 5. What is the most common neurovascular injury
B. External rotation anterior-posterior (AP) shoul- associated with an anterior shoulder dislocation?
der X-ray A. Musculocutaneous nerve
C. Axillary X-ray B. Axillary nerve
D. Internal rotation AP shoulder X-ray C. Axillary vein
E. Chest X-ray D. Subclavian artery
E. Radial nerve
3. While reviewing a chest CT obtained as part of the
initial workup, you note a displaced right scapular
fracture. What additional injuries are most ANSWERS
commonly associated with scapular fractures? 1. C. Scapulothoracic dissociation results rom com-
A. Pulmonary injury plete disruption o the scapulothoracic articulation
B. Head Injury with associated lateral translation o the scapula

without associated partial or complete amputation o
the so tissue, with the overlying skin typically intact.
Scapulothoracic dissociation typically results rom
a high energy, traction orce, to the upper extrem-
ity. Motorcycle accidents are the most commonly
described mechanism in the literature. Considered
analogous to a closed orequarter amputation, it is
associated with a myriad o concomitant injuries
including: dislocation o the acromioclavicular and
sternoclavicular joints, clavicle racture, vascular
injury to the subclavian and axillary vessels, brachial
plexus injuries, and complete or partial disruption o
the surrounding musculature.
T e clinician must maintain a high index o sus-
picion as patients are o en obtunded, sedated, or
intubated during initial evaluation, preventing a
complete neurological examination. Additionally,
because these injuries are associated with a high
energy mechanism and severe and potentially li e
threatening concomitant injuries, scapulothoracic
dissociation can be missed or overlooked, without
appropriate and complete evaluation. ypically these
patients will have signi cant swelling and edema o
the entire shoulder girdle rom neck to axilla rom
underlying hematoma. Evaluation and comparison
o pulses o the upper extremity should be promptly
per ormed, and i absent or uneven, urther studies
including arterial pressure indexes, and i abnormal
(< 0.9), arteriogram should be obtained.
With the low incidence o injury, outcomes studies
are limited. However, previous studies have suggested
a mortality rate o roughly 20% (3 o 15 patients),
though the true rate is likely higher as a result o
death rom associated injuries in these patients.
Associated neurovascular injury is extremely com-
mon, with neurologic injury in 94% o patients and
vascular injury in 88%. In addition to a mortality rate
between 10% to 20%, outcomes are universally poor
with 52% rate o ail extremity and early amputation
rate o 21%. Early recognition o scapulothoracic
injury, and likely associated neurovascular injury, is
paramount as diagnosis guides treatment and e ects
long term outcomes.
2. E. T e diagnosis o scapulothoracic dissociation can
be made based on a non-rotated chest X-ray. Lat-
eral displacement o the scapula is pathognomonic.
Comparison o the scapular position can be made
with the contralateral side, and di erences and asym-
metry noted. T e amount o scapular lateralization,
C H AP TER 9 9 S H o u l d ER TRAu m A 381
or scapular-index, can be measured. T e distance
rom the sternal notch or midline o the spine to
the glenoid or medial border o the scapula can be
measured and compared with the contralateral side.
T e injured side measurement is divided by the non-
injured side measurement. T e normal scapular-
index is about 1.09, and in one o the largest series,
the ratio in patients with a scapulothoracic dissocia-
tion averaged 1.29.
3. A. In a review o 58 scapula ractures as a result o
blunt trauma T ompson et al ound a high rate o
concomitant injury to the ipsilateral lung, chest wall,
and chest contents. Fi y-three percent o patients
had a pulmonary contusion, 53% rib ractures, 26.8%
clavicle ractures. Neurovascular injury was not
uncommon, with a incidence o brachial plexus
injury o 12.5% and a 10.7% incidence o subclavian,
brachial, or axillary artery injury.
Baldwin et al. controlled or injury severity score
in order to determine i commonly associated inju-
ries with scapula ractures were simply a result o an
increased injury severity score. T ey showed the ol-
lowing injuries had increased requency in patients
with a scapula racture compared to those without:
rib ractures, pneumothorax, lung injury, ipsilateral
extremity injury, and spine injury.
A scapula racture, with a high energy blunt
mechanism o injury, should alert the clinician to the
possibility o additional injury to the ipsilateral lung,
chest wall, shoulder girdle, and surrounding neuro-
vascular structures.
4. D. Based on the clinical exam ndings present, the
patient has a suspected shoulder dislocation. Anterior
shoulder dislocations are by ar the most common,
accounting or approximately 98% o all gleno-
humeral dislocations. T e typical mechanism or an
anterior dislocation is with the arm in an abducted
and externally rotated position. Posterior disloca-
tions are relatively rare, and result rom axial load to
an adducted, exed and internally shoulder, and can
also be associated with electrical shocks or seizures.
An acutely dislocated shoulder is typically very
pain ul. T e patient with an anterior dislocation will
typically hold the arm in slight abduction and range
o motion will be limited secondary to pain.
Radiographs are an essential part o the ini-
tial assessment, ensuring appropriate diagnosis
including the direction o dislocation, presence o
382 G EN ERAl S u RG ERY EXAm I N ATIo N AN d Bo ARd REVI EW
associated ractures, and potential blocks to reduc-
tion. T e standard shoulder trauma series must
include orthogonal X-rays including a true AP, axil-
lary lateral and scapular Y view. Obtaining only a
single view o the shoulder can lead to missed injury
and inaccurate diagnosis. C can help aid in diagno-
sis i appropriate imaging cannot be obtained.
A er appropriate diagnosis is made, a reduction
can be per ormed. T ere are several classic meth-
ods or relocation including the Kocher, traction-
counter traction, Stimson and Milch to name a ew.
Newer studies and techniques ocus on limiting pre-
medication. Recent meta-analysis have shown equiv-
alent e ectiveness using an intra-articular lidocaine
injection instead o intravenous analgesia and seda-
tion or manual acute closed reduction o anterior
shoulder dislocation with decreased risk o post pro-
cedure complications.
5. B. T e axillary nerve (C5,C6) is a direct continuation
o the posterior cord o the brachial plexus. Because
it is tethered, anterior and posterior, to the gleno-
humeral joint with limited excursion, it is susceptible
to injury rom shoulder dislocation. In a study o 105
patients with acute primary anterior shoulder dislo-
cations, 21% o patients (22/107) were ound to have
a nerve injury, the most common (n = 13) involving
injury to the axillary nerve. T e authors o this study
note that the incidence o nerve injury may have been
underestimated as it was diagnosed by clinical exam-
ination alone, not with electrophysiologic testing.
In a prospective study o 101 consecutive patients
with anterior shoulder dislocation or humeral neck
racture, de Laat et al. ound electrophysiologic evi-
dence o nerve injury in 45% o patients. T e axillary
nerve was most commonly injured (37%) ollowed
by the suprascapular nerve (29%) and the muscu-
locutaneous nerve (22%).
Initial diagnosis o a nerve injury can be dif cult
secondary to pain. Detailed initial exam and assess-
ment, additional ollow up or repeat examination,
or electrophysiologic testing, can help detect injury
early, and potentially prevent long term poor unc-
tional outcome.
BIBLIOGRAPHY
Baldwin KD, Ohman-Strickland P, Mehta S, et al. Scapula
ractures: A marker or concomitant injury? A retrospec-
tive review o data in the National rauma Database.
J rauma. 2008;65:4305.
Brucker PU, Gruen GS, Kau mann RA. Scapulothoracic
dissociation: Evaluation and management. Injury.
2005;36:114755.
Damschen DD, Cogbill H, Siegel MJ. Scapulothoracic disso-
ciation caused by blunt trauma. J rauma. 1997;42:53740.
de Laat EA, Visser CP, Coene LN, et al. Nerve lesions in pri-
mary shoulder dislocations and humeral neck ractures. A
prospective clinical and EMG study. J Bone Joint Surg Br.
1994;76:3813.
Eachempati KK, Dua A, Malhotra R, et al. T e external rota-
tion method or reduction o acute anterior dislocations
and racture-dislocations o the shoulder. J Bone Joint Surg
Am. 2004;86-A:24314.
Ebraheim NA, An HS, Jackson W , et al. Scapulothoracic dis-
sociation. J Bone Joint Surg Am. 1988;70:42832.
Flanagin BA, Leslie MP. Scapulothoracic dissociation. Orthop
Clin North Am. 2013;44:17.
Jiang N, Hu YJ, Zhang KR, et al. Intra-articular lidocaine ver-
sus intravenous analgesia and sedation or manual closed
reduction o acute anterior shoulder dislocation: An
updated meta-analysis. J Clin Anesth. 2014;26:3509.
Kelbel JM, Jardon OM, Huurman WW. Scapulothoracic dis-
sociation. A case report. Clin Orthop Relat Res. 1986;2104.
Krieg JC, Green A, Cole PA. In: Schmidt AH, eague DC, eds.
Orthopedic Knowledge Update 4: Shoulder rauma. 1st ed.
Rosemont, IL: American Academy o Orthopedic Sur-
geons; 2010:18194.
Nagi ON, Dhillon MS. raumatic scapulothoracic dissociation.
A case report. Arch Orthop rauma Surg. 1992;111:3489.
Oreck SL, Burgess A, Levine AM. raumatic lateral displace-
ment o the scapula: A radiographic sign o neurovascular
disruption. J Bone Joint Surg Am. 1984;66:75863.
Robinson CM, Aderinto J. Posterior shoulder dislocations and
racture-dislocations. J Bone Joint Surg Am. 2005;87;639
50.
Rockwood CA, ed. T e Shoulder. Philadelphia, PA: Saunders
Elsevier; 2009.
Rubin SA, Gray RL, Green WR. T e scapular Y: A diagnostic
aid in shoulder trauma. Radiology. 1974;110:7256.
te Slaa RL, Wij els MP, Brand R, Marti RK. T e prognosis
ollowing acute primary glenohumeral dislocation. J Bone
Joint Surg Br. 2004;86:5864.
T ompson DA, Flynn C, Miller PW, et al. T e signi cance o
scapular ractures. J rauma. 1985;25:9747.
Zelle BA, Pape HC, Gerich G, et al. Functional outcome ol-
lowing scapulothoracic dissociation. J Bone Joint Surg Am.
2004;86(1):28.
 100
Pediatric Musculoskeletal rauma
Kelly G. Kilcoyne
While on your pediatric rotation, you are called to a
trauma code in the emergency room. T e patient is a
6-year-old emale who was restrained in the back seat
o a car when it lost control and went over an embank-
ment. When you arrive, the child is conscious and
breathing spontaneously. Initial vitals are stable and she
is ollowing commands. T e child is in signi cant pain,
but is able to communicate to you that her right elbow
and le leg hurt.
1. With regards to pediatric trauma surgery patients,
compared to adult trauma patients, the ormer
has:
A. Small head:body ratio
B. Larger total blood volume
C. Decreased capacity or plastic de ormation
D. Increased baseline metabolic rate combined with
a larger physiologic reserve
E. Smaller sur ace area to body volume
2. A er your initial assessment you begin to order
labs and imaging. In consideration o cervical
spine evaluation, you make the ollowing decision:
A. Cervical spine radiographs are not indicated but
lumbar spine radiographs are, because lumbar
spine injuries are more common in children.
B. Cervical spine radiographs are indicated because
she may have lost consciousness.
C. Cervical spine radiographs are not indicated
because children are unlikely to sustain injury to
the cervical spine as a result o their unique osse-
ous anatomy.
D. Cervical spine radiographs are indicated as a
result o the mechanism o injury and potential
distracting injuries o her le leg and right elbow.
E. Cervical spine radiographs are not indicated, but
a magnetic resonance imaging (MRI) o her cer-
vical and thoracolumbar spine is.
3. Upon urther evaluation o her right elbow, you
notice an obvious de ormity. What is your initial
step in management o this potential injury?
A. Obtain labs to rule out in ection.
B. Obtain a computerized tomography (C ) scan
to evaluate potential racture.
C. Per orm a care ul neurovascular examination.
D. Per orm a closed reduction, then obtain X-rays.
E. Provide sedation to allow evaluation o stability
and range o motion.
4. Radiographs o the le emur demonstrate a
displaced midsha racture. How would the
workup o this emur racture dif er, i at all, i the
child was a non-ambulatory 11 month old, injured
as a result o a all?
A. Obtain labs to rule out in ection.
B. Obtain a C scan to urther evaluate the racture.
C. Obtain inlet and outlet pelvic X-rays.
D. T e child would need to be evaluated or pos-
sible child abuse.
E. T e workup would be unchanged.
384 G EN ERAL S U RG ERY EXAM IN ATIO N AN D BO ARD REVI EW
ANSWERS
1. D. T ere are many important di erences in the
anatomy, physiology, mechanism, and characteristics
o injuries that make pediatric trauma unique. T e
proportions o a childs body are di erent rom those
o an adult, predisposing to certain injuries. Children
have a large head to body ratio; the younger the child
the more disproportionate the ratio. T eir relatively
larger heads predispose them to head, neck, and
upper cervical spine injuries.
Pediatric bone growth and development is incom-
plete, with bone more de ormable and able to rac-
ture with (relatively) less orce. T ese characteristics
can lead to internal organ damage without apparent
injury or racture o the thoracic rib cage. Addition-
ally, the immature cage leaves the spleen and liver
exposed and vulnerable to injury.
Children have a smaller total blood volume
(80 mL/kg) than adults.As a result, equivalent or small-
volume blood loss can have more signi cant physi-
ologic consequences, with hypovolemia developing
more rapidly. Additionally, because o a higher base-
line metabolic rate and increased physiologic reserve,
the apparent hemodynamic response to trauma may
be minimal. Additionally, children have a more mini-
mal metabolic response to trauma, and hypotension
is o en a late sign o shock in these patients. T ey
are also more prone to hypothermia because o an
increased ratio o body sur ace area to volume.
2. D. T e pediatric spine, especially in children under
8 years old, has many important anatomic and bio-
mechanical di erences that predispose it to cervical
injury. As previously stated, children have a larger
head to neck ratio. Additionally, in early childhood,
the ulcrum o exion is at the C2-C3 level, com-
pared to C5-C6 by age 11. T is too, predisposes to
upper cervical spine injury. Pediatric cervical spine
trauma may present as racture, racture with sub-
luxation, subluxation alone (without racture), or
spinal cord injury without radiographic abnormal-
ity (SCIWORA). T e incidence o SCIWORA and
isolated so tissue injury alone are more common in
children < 9 years old. As a result o these, and other,
complicating actors, the assessment and clearance
o pediatric patients with potential spine injuries is
challenging. Incomplete and inaccurate assessment
can result in missed cervical spine injuries while pro-
longed can be associated with signi cant morbidity.
Lee et al. developed a multidisciplinary approach
to pediatric cervical spine injury evaluation and
clearance. T e authors use the presence o any o
the ollowing as a reason or immobilization and
radiographic evaluation; child is unconscious or
inconsolable, mechanism o injury suggestive o
possible cervical spine injury (motor vehicle crash,
all rom height, pedestrian struck, etc.), neck pain
or ocal neck tenderness, presence o a distracting
injury, abnormal neurologic exam ndings or his-
tory o transient neurologic symptoms that suggest
c-spine injury, physical signs o neck trauma, sig-
ni cant trauma to head and or ace, or an unreliable
exam secondary to substance abuse. In short, in the
multiply injured patient, a cervical spine is presumed
present and must be ruled out by physical exam and
radiographic evaluation.
3. C. Pediatric elbow injuries present a challenge to the
treating physician because diagnosis, physical exam-
ination, radiographic evaluation and interpretation,
and surgical treatment can all be dif cult. Addition-
ally, complications, both acute and chronic, are not
uncommon. Un ortunately, while ractures around
the elbow can be dif cult, they are also quite com-
mon. Elbow injuries in children occur more com-
monly than in adults, and account or approximately
30% o all extremity ractures in patients age 0 to
7 years. Injuries to the upper extremity account or
65% o all ractures and dislocations in children, with
ractures o the distal end and orearm being most
common, ollowed by ractures and dislocations o
the elbow. O all pediatric elbow ractures, supracon-
dylar ractures are the most common.
While physical examination in the uncoopera-
tive child with a swollen elbow can be challenging,
it is absolutely essential, and should be the rst
step in treatment. T e two most important aspects
o the exam are the neurovascular assessment and
the presence o any so tissue injury. Examination
and documentation o neurovascular status must
be completed prior to any reduction, and ollow
and reduction maneuver, to assess or any interval
change. For supracondylar distal humerus ractures
speci cally, neurologic injury is relatively common,
ranging rom 10% to 18%.
Supracondylar humerus ractures requiring xa-
tion were previously thought to be a surgical emer-
gency. However, there has been a shi in thinking
that those ractures without vascular compromise,
 C H AP TER 1 0 0 P ED IATRIC M U S C U LO S k ELETAL TRAU M A
severe so tissue swelling, or pressure on the skin
can wait (i.e., wait until morning) until an OR team
amiliar with this operation is available. Again, this
decision hinges and underlines the importance o
accurate and complete physical examination. How-
ever, these patients must be splinted and admitted or
observation with continued neurovascular checks
until surgery can sa ely be per ormed.
4. D. Pediatric diaphyseal emur racture rates continue
to increase, accounting or 1.4% to 1.7% o all pedi-
atric ractures. T ey are the most common reason or
hospitalization in a pediatric patient with orthopedic
injury. reatment o these ractures is largely depend-
ent on patient age: in ants, 6 months to 5 years, 5 to 11
year olds, and patients age 11 to skeletal maturity. T e
child in our example would likely be treated opera-
tively with exible intramedullary nails.
T e treating physician o a child < 36 months old
with a emur racture has to consider, and rule out,
non-accidental trauma as the cause o injury, accord-
ing to the Academy o Orthopedic Surgeons clinical
guidelines. T e recommendation is based on Level
II studies which reported that 14% o emur rac-
tures were the result o child abuse in children aged
0 to 1 year, and 12% in patients aged 0 to 3 years.
T is evaluation should include a complete history
and physical, direct communication with the childs
pediatrician or physician, and i available, consulta-
tion with a child abuse team. Additionally, a selective
skeletal survey should be ordered i elt appropriate
by the treating physician.
T e true incidence o child abuse and related rac-
tures is likely underestimated as a result o underre-
porting. T e consequences o missing a case o abuse
can result in serious complications including contin-
ued abuse or death.
BIBLIOGRAPHY
Cheng JC, Lam P, Shen WY. Closed reduction and percu-
taneous pinning or type III displaced supracondylar
ractures o the humerus in children. J Orthop Trauma.
1995;9:51115.
dAmato C. Pediatric spinal trauma: injuries in very young
children. Clin Orthop Relat Res. 2005;(432):3440.
385
Dormans JP, Squillante R, Shar H. Acute neurovascular com-
plications with supracondylar humerus ractures in chil-
dren. J Hand Surg Am. 1995;20:14.
Eleraky MA, T eodore N, Adams M, et al. Pediatric cervical
spine injuries: report o 102 cases and review o the litera-
ture. J Neurosurg. 2000;92:1217.
Green NE, Van Zeeland N. Fractures and Dislocations About
the Elbow. In: Green N, Swiontkowski MF, eds. Skeletal
Trauma in Children. 4th ed. Philadelphia, PA: Elsevier;
2009:207282.
Hanlon CR, Estes WL, Jr. Fractures in childhood: A statistical
analysis. Am J Surg. 1954;87:31223.
Hinton RY, Lincoln A, Crockett MM, et al. Fractures o the
emoral sha in children. Incidence, mechanisms, and
sociodemographic risk actors. J Bone Joint Surg Am.
1999;81:5009.
Jones M, Anderson PA, Noonan KJ. Pediatric cervical spine
trauma. J Am Acad Orthop Surg. 2011;19:60011.
Kocher MS, Sink EL, Blasier RD, et al. reatment o pediat-
ric diaphyseal emur ractures. J Am Acad Orthop Surg.
2009;17:71825.
Lee SL, Sena M, Greenholz SK, et al. A multidisciplinary
approach to the development o a cervical spine clearance
protocol: Process, rationale, and initial results. J Pediatr
Surg. 2003;38:35862; discussion 35862.
Lichtenberg RP. A study o 2,532 ractures in children. Am J
Surg. 1954;87:3308.
McCartney D, Hinton A, Heinrich SD. Operative stabiliza-
tion o pediatric emur ractures. Orthop Clin North Am.
1994;25:63550.
Mohseni S, alving P, Branco BC, et al. E ect o age on cervi-
cal spine injury in pediatric population: a National rauma
Data Bank review. J Pediatr Surg. 2011;46:17716.
Osenbach RK, Menezes AH. Pediatric spinal cord and verte-
bral column injury. Neurosurgery. 1992;30:38590.
Otsuka NY, Kasser JR. Supracondylar Fractures o the Humerus
in Children. J Am Acad Orthop Surg. 1997;5:1926.
Rewers A, Hedegaard H, Lezotte D, et al. Childhood emur rac-
tures, associated injuries, and sociodemographic risk actors:
A population-based study. Pediatrics. 2005;115:e543552.
Sahlin Y. Occurrence o ractures in a de ned population: A
1-year study. Injury. 1990;21:15860.
Skaggs DL. Elbow Fractures in Children: Diagnosis and Man-
agement. J Am Acad Orthop Surg. 1997;5:30312.
Weisman DS, Frick SL. CH 44 Problematic Pediatric Frac-
tures in textbook Orthopaedic Knowledge Update: trauma
4 1st ed. Schmidt A, eague D eds. Rosemont, IL: American
Academy o Orthopaedic Surgeons; 2010:57987.
Wilber JH, T ompson GH, Son-Hing J. T e Multiply Injured
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Trauma in Children. 4th ed. Philadelphia, PA: Elsevier;
2009:5783.
 101
Knee Injuries
Jeremy McCallum and Douglas Rowles
SCENARIO 1
A 27-year-old healthy male is transported to the emer-
gency department a er a motor vehicle crash. He was a
restrained driver in a head on collision with another car
and was reportedly traveling about 55 mph. His vehicles
airbag deployed. T e responding medics report he was
responsive at the scene and complained o isolated right
knee pain with numbness and tingling to his right lower
extremity below the knee.
A head to toe assessment by the on call trauma team
in the emergency department con rms injury is local-
ized to the right lower extremity. Physical examination
reveals signi cant so tissue swelling around the right
knee with de ormity but so and supple leg muscular
compartments, a 2 cm bleeding laceration along the
anterolateral aspect o the knee, and di use numbness
o the right oot and lateral leg. Both the dorsalis pedis
and posterior tibial pulses are palpable but noticeably
weaker compared to his contralateral extremity. His
motor examination reveals signi cant weakness with
oot and great toe dorsi exion but the exam is limited
due to pain.
1. A er applying a saline-soaked dressing and ace
wrap to the wound, initial management in the
emergency department should include which o
the ollowing?
A. A computerized tomography (C ) scan o his
head, abdomen, pelvis, and C angiography o
the right lower extremity.
B. Immediate right leg compartment pressure
testing.
C. Immediate portable X-Rays o his right hip, knee,
and lower extremity.
D. Admit or observation, antibiotics, and serial
examinations.
E. ransport to the OR or irrigation, exploration,
debridement o the open wound, and other pro-
cedures as indicated.
2. X-ray assessment o the knee and leg reveals a
posteromedial knee dislocation without obvious
ractures. X-rays o the hip, emur, and below the
knee are normal. Regarding the neurovascular
status o the right lower extremity, which o the
ollowing should be the next step in management?
A. Immediate transport to the OR or open reduc-
tion and vascular repair.
B. Obtain immediate vascular studies including an
angiography.
C. Conscious sedation ollowed by closed reduction
and reassessment o distal pulses and neurologic
exam.
D. Operative washout o the wound and knee joint
reduction ollowed by ice, elevation, and obser-
vation o neurovascular status.
E. Immediate re erral to orthopedic surgery.
3. Regarding vascular injury associated with knee
dislocations, which o the ollowing statements is
true?
A. T e incidence o injury to the popliteal artery is
low (< 2%).
B. Vascular repair can be delayed up to 24 hours, a er
which amputation rates dramatically increase.

C. Physical exam alone is suf cient in detecting all
vascular injuries a er knee dislocation.
D. A er reduction and return o pulses, serial
examinations at least every 4 to 6 hours or a
minimum o 48 hours is necessary to monitor
or late-developing complications.
E. Normal pulses rule out an arterial or venous
injury.
4. Assuming injury to the popliteal artery is conf r-
med preoperatively, which statement regarding
surgical management is correct?
A. Vascular repair should be completed ollowed by
splinting prior to orthopedic consultation.
B. Orthopedic re erral or immediate ligament
repair or reconstruction is indicated prior to vas-
cular repair.
C. Vascular repair and management o the open
wound should be completed ollowed by bracing
and outpatient rehabilitation o the ligamentous
knee injury.
D. Vascular repair and management o the open
wound should be completed. Reconstructive
knee surgery is typically not needed due to post
traumatic sti ness.
E. Vascular repair and orthopedic surgical manage-
ment should occur simultaneously.
5. Regarding neurovascular injuries associated
with knee dislocations, which o the ollowing
statements is correct?
A. T e incidence o neurovascular compromise
increases proportionately with increasing energy
o injury.
B. Delayed recognition o an associated vascular
injury signi cantly increases the chance o poor
unctional outcomes or limb loss.
C. Neurovascular injury is unlikely in low energy
injuries.
D. T e most common neurologic injury associated
with knee dislocation is tibial nerve injury.
E. All o the above statements are correct.
SCENARIO 2
A 62-year-old emale is transported to the emergency
department due to injuries incurred as a restrained
ront seat passenger in a roll-over motor vehicle acci-
dent. She has a past medical history signi cant or type
2 diabetes, hypertension, hyperlipidemia, and hypothy-
roidism. During the trauma assessment, she is noted to
C H AP TER 1 0 1 Kn EE In j u RI Es 387
have a pneumothorax, multiple acial contusions, and a
closed injury to her right knee. Focused examination o
the knee reveals severe so tissue swelling, mild blister-
ing o the skin over the anterior portion o her knee but
no open wounds and signi cant di use pain with active
and passive motion. Her distal neurovascular exam is
intact. X-rays o the knee reveal a displaced tibial pla-
teau racture.
1. Management o her knee injury should include
which o the ollowing?
A. Urgent surgical treatment with open reduction
and internal xation.
B. Urgent de nitive surgical treatment with exter-
nal xation.
C. Long leg casting until bony union.
D. Splint versus external xation until so tissue
swelling resolves ollowed by open reduction
and internal xation.
E. Splint versus knee immobilizer until so tissue
swelling resolves ollowed by use o a bone stim-
ulator, unctional bracing, and physical therapy.
2. Which o the ollowing may be a concomitant knee
injury to a tibial plateau racture?
A. Meniscus tear
B. Ligament tear
C. Osteochondral or chondral injury to the articu-
lar sur ace
D. Knee capsule tear
E. All o the above
3. Which o the ollowing actors most strongly
predicts an increased risk o leg compartment
syndrome in this patient?
A. Severity o so tissue swelling
B. Integrity o the knee joint capsule
C. ime since injury
D. Amount o displacement o the tibial racture
E. ourniquet time during surgery
SCENARIO 3
A 19-year-old male patient presents to the emergency
department a er sustaining a le knee injury earlier
that day playing basketball. He reports a similar injury
to this knee a year previously, a er which he has had re-
quent episodes o his knee giving way. Physical exami-
nation reveals an e usion and so tissue swelling about
the knee. He has pain but is able to ully ex and extend
the knee. X-ray examination o the knee is normal but
388 G En ERAL s u RG ERY EXAM I n ATI O n An D BO ARD REVI EW

an magnetic resonance imaging (MRI) scan obtained ANSWERS TO SCENARIO 1

the next day reveals a complete tear o the anterior cru-
ciate ligament. 1. C. A er evaluation and stabilization o the patient
radiographs should be obtained to con rm the diag-
1. Which o the ollowing physical examination tests nosis. Radiographs should not unnecessarily delay the
is most reliable at diagnosing an anterior cruciate reduction o the knee. Given up to 50% o knee dis-
ligament (ACL) tear? locations can undergo a spontaneous reduction prior
A. Anterior drawer test to radiographs, normal radiographs do not rule out a
B. Lachman test knee dislocation. Rim ractures, joint asymmetry, avul-
C. Pivot shi test sion ractures, and mild subluxation o the tibio emoral
D. McMurrey test joint may be the only radiographic nding. An MRI
E. Apley compression test o the knee can be obtained on an elective basis once
the patient is acutely stabilized and is the diagnostic
2. What is the most likely associated knee injury with imaging modality o choice. T e question stem states
an acute ACL tear? this is an isolated injury making option A incorrect.
A. Medial collateral ligament tear Compartment syndrome in a knee dislocation is not
B. Medial meniscus tear uncommon and may be secondary to the initial trauma,
C. Lateral eniscus tear hemorrhage, or reper usion o an ischemic limb.
D. Medial patello emoral ligament tear Answer B, a low threshold to measure compart-
E. Medial joint impaction racture (bone contu- ment pressures is appropriate; however, obtaining
sion) radiographs and attempting reduction o the knee
are the more appropriate answer. T e patient needs
3. Initial management o this patient should include urther workup be ore D or E would be applicable.
all o the ollowing except?
A. A course o anti-in ammatory medications 2. C. Once a knee dislocation is identi ed, emergent
(NSAIDS). closed reduction with sedation should be attempted.
B. Re erral to orthopedic surgery or reconstructive T e reduction maneuver depends on the direction
knee surgery. o dislocation and generally involves gentle traction-
C. Re erral to physical therapy. countertraction. T e reduction should be per ormed as
D. Knee immobilization in a brace until swelling is atraumatically as possible with sedation (i needed to
resolved. avoid urther damage). Occasionally the injuries can-
E. Re erral or a well- tted ACL brace. not be reduced in a closed ashion. In a posteriolateral
dislocation, the medial emoral condyle buttonholes
4. Which o the ollowing is NOT an acceptable through the joint capsule and/or the medial collateral
alternative as a gra option or ACLreconstruction ligament,causing a puckering o the skin and preventing
in this patient? a closed reduction I closed reduction ails, the patient
A. Autologous Ipsilateral Patellar endon Gra . is indicated or emergent surgical reduction. Answers
B. Autologous Quadrupled Hamstring endon A, B, and D are incorrect because a closed reduction
Gra t. has not been attempted. A er reduction, the injured
C. Contralateral Patellar endon Gra . knee is requently unstable and should be placed into a
D. Allogra (Donor) endon Gra . long leg splint (above the knee splint) in approximately
E. All o the above are acceptable gra options. 20 degrees o exion to prevent posterior subluxa-
tion o the tibia. A circum erential splint/cast should
5. Which o the ollowing is the most likely be avoided to help prevent compartment syndrome.
complication o ACL reconstructive surgery? Post-reduction radiographs should be obtained to con-
A. Sti ness rm adequate reduction. A er reduction the vascular
B. Intra-articular in ection assessment should be repeated. Answer E, re erral to an
C. Deep venous thrombosis (DV ) orthopedic surgeon, is recommended or a knee dis-
D. Iatrogenic neurovascular injury location however reduction should not be needlessly
E. Gra ailure delayed while waiting or a consultation.

3. D. Vascular injuries associated with ractures/
dislocations are relatively uncommon, but there is a
strong association with posterior knee dislocations
and popliteal artery/vein injuries. Answer A, the rate
o popliteal artery injury, has been reported to range
rom 14% to 65%. Multiple algorithms have been
published or assessment o the vascular status o the
lower extremity in the incidence o suspected knee dis-
location. Initially, a physical exam should be per ormed
assessing both posterior tibial and dorsalis pedis pulses
in comparison to the contralateral extremity. Answer
C/E, normal pulses, do not rule out a vascular injury.
In the presence o hard signs o ischemia (cool,
pulseless, obviously dysvascular extremity) vascular
surgery consultation should be obtained immediately.
However, when a patient presents with so signs o
ischemia (asymmetric pulses and/or warmth), urther
assessment is warranted. Measurement o the ankle-
brachial index (ABI) can augment the physical exam.
An ABI > /= 0.9 is reassuring that there is no clini-
cally signi cant vascular injury. However, choice D is
correct because delayed thrombus is a continued risk,
making reassessment every 4 to 6 hours important.
I the ABI is abnormal, urther studies are indicated.
Either an arterial ultrasound, which is technician
dependent and may not always be available, or C
angiography versus conventional angiography should
be completed. Emergent vascular repair is indicated i
a signi cant injury is identi ed, with the (B) amputa-
tion rate as high as 86% in cases where vascular repair
was delayed greater than 8 hours.
4. E. I a vascular injury is identi ed both vascular and
orthopedic surgery should be urgently consulted.
T e key to this question is that both teams will need
to work simultaneously in stabilizing and restor-
ing blood ow to the lower extremity. Answers A
and C are incorrect because vascular repair without
stabilizing the leg will likely ail. Answer B is incor-
rect because restoring vascular ow to the leg is the
rst priority and should be done within 8 hours and
answer D is incorrect because reconstructive knee
surgery will be needed to protect the vascular repair
and regain unctional range o motion in the short
term as well as to prevent long term knee instability.
5. B. Multiple series have demonstrated that sub-
optimal unctional outcomes and even amputa-
tion can result when there is delayed recognition
o an associated injury to the popliteal vessels, and
C H AP TER 1 0 1 Kn EE I n j u RI Es 389
all knee dislocations should be assumed to have a
vascular injury until it has been ruled out. Several
studies have also demonstrated an increased inci-
dence o these injuries among obese patients versus
non-obese. Answers A and C are incorrect because in
a review o low energy dislocations, 41% were ound
to have a vascular injury. T is is comparable to the
vascular injury rates o cohorts with combined (low
and high energy and high energy injuries). T e most
commonly injured nerve in a knee dislocation is the
peroneal nerve, not the (D) tibial nerve. Neurologic
injury occurs in 16% to 40% o knee dislocations.
Less than 50% o patients with peroneal nerve inju-
ries have nerve recovery.
ANSWERS TO SCENARIO 2
1. D. Displaced tibial plateau ractures greater than
0.5 to 1 cm are managed with operative reduction
and xation (answers C and E). Protected mobi-
lization can be used or ractures that are non- to
minimally displaced with a stable ligamentous exam.
High energy injuries can lead to severe injury to the
overlying so tissue as demonstrated by swelling
and racture blisters. Bicondylar ractures, racture-
dislocations, and sha dissociated ractures have
worse so tissue injury. De nitive surgical reduction
and treatment should be delayed in high energy inju-
ries until the so tissue envelop allows (answer A).
In high energy trauma, it may take 8 to 21 days or the
swelling to subside and skin conditions to improve.
Interval treatment can range rom a well applied
splint to temporary spanning external xation. T e
goal is to maintain length and alignment until de ni-
tive xation can be pre ormed and post-reduction
radiographs should be obtained. raction radio-
graphs and/or post reduction C scan can be help ul
in evaluation and planning o treatment. Even with
staged management o these ractures. in ection rates
still range rom 8.4% to 18%.
2. E. Regarding answers A and B, meniscal tears occur
in up to 50% o plateau ractures. Ligamentous inju-
ries occur in approximately 30% to 77% o ractures.
Answers C and D are incorrect because capsular tears
and chondral injury can both be present as part o
the injury pattern. Segond ractures, reverse Segond
ractures, anteromedial tibial margin ractures, and
semimembranosus tendon insertion site ractures
are all evidence o associated injuries.
390 G En ERAL s u RG ERY EXAM I n ATI O n An D BO ARD REVIEW

3. D. T e rate o compartment syndrome in tibial Answer D is correct because prolonged immobili-

plateau ractures is 10% to 15%. Presenting symptoms
include pain out o proportion to injury, swelling,
pain on passive stretching, pallor, absence o pulses,
hyperesthesia, and motor weakness. Physical exam
can be unreliable (answer A) and i suspected,
leg muscular compartmental pressures should be
assessed. T e amount o displacement (correct
answer D) as well as a higher Shatzker and/or OA/
O A classi cation are associated with increased risk
o compartment syndrome. Repeat examination o
the leg or compartment syndrome should be contin-
ued at regular intervals because it can occur 24 hours
or more a er injury (answer C).
zation should be avoided as it may lead to arthro -
brosis. Regarding choice E, the use o an ACL brace
continues to be controversial and has become an indi-
vidualized and optional part o the treatment plan.
Patients should be re erred to an orthopedic surgeon
or counseling o treatment options. T e ideal candi-
date or surgical reconstruction is the patient with an
acute ACL de ciency and an active li estyle as well as
one with a chronic injury and unctional instability
with normal daily activities.

ANSWERS TO SCENARIO 3
P oplite a l a .
1. B. T e Lachman test is the most sensitive physical
Me dia l s upe rior La te ra l s upe rior
exam maneuver to test or ACL laxity. T e knee is ge nicula r a . ge nicula r a .
placed in 20 to 30 degrees o exion, the emur is sta- S ura l a a .
bilized, and an anteriorly directed orce is applied to La te ra l infe rior
ge nicula r a .
the tibia. T e examiner should estimate the distance Me dia l infe rior
o translation as well as whether there is an endpoint ge nicula r a . P os te rior tibia l
re curre nt a .
or not. T e pivot shi test and anterior drawer test Ante rior tibia l a .
are other physical examination maneuvers testing Ante rior tibia l
Tibia l-pe rone a l trunk re curre nt a .
the anterior cruciate ligament, however, they are not
as reliable as the Lachman exam. T e Mcmurray test
and Apley compression test are a physical exams Fibula r a .
evaluating the meniscus not the ACL.
P os te rior tibia l a .
2. C. Meniscal tears are the most common associated
injury seen with an ACL tear. T ey occur in 65%
to 75% o patients. Lateral meniscal tears are more
common in acute ACL injuries. Answer B is incorrect
because medial meniscus tears are more requently
seen in chronic injuries but less prevalent in acute
injuries. Bone bruises or trabecular micro ractures Communica ting
bra nch
occur in just over hal the patient with an ACL injury,
however, these are typically located along the lateral
Me dia l ma lle ola r La te ra l ma lle ola r
emoral condyle and the posterolateral proximal bra nche s bra nche s
tibia. T ese are a result o the subluxation and spon-
taneous reduction o the knee joint that occurs dur- Me dia l pla nta r a . Ca lca ne a l
bra nche s
ing an injury that leads to knee ligament disruption.
Approximately 33% o patients with an ACL tear will
have at least one additional ligament injured. Regard- Posterior view of leg vasculature
ing choice A, the medial collateral ligament is injured
in about 7% o patient with an ACL injury. 4. E. Gra selection depends upon patient actors and
surgeon pre erence. Multiple options o gra s are avail-
3. D. Answers A and C are incorrect because the able or ACL reconstruction. Both autogra and allo-
treatment or a suspected ACL tear includes pain gra are utilized. Autogra options include quadrupled
control, MRI, and physical therapy or mobilization. hamstring tendons, bone-patellar tendon-bone, and

quadriceps tendon. Allogra options are varied and
include bone-patellar tendon-bone, achilles tendon,
hamstring tendons, anterior tibialis tendon, and poste-
rior tibialis tendons. Generally speaking, the results o
ACL reconstruction with any o these gra options are
acceptable, although there are speci c clinical scenarios
that can lend themselves to certain choices. A lengthy
discussion with the patient, outlining the positives and
negatives o the gra choices is requently needed.
5. A. Sti ness ollowing ACL reconstruction or arthro -
brosis is the most common complication a er surgi-
cal reconstruction. It is likely related to in ammation
a ecting the synovial lining leading to thickening o
the capsule and loss o the normal space within the
joint. Proper surgical technique and rehabilitation can
help reduced the risk o joint sti ness. Loss o exten-
sion is reported to be as high as 59% in some popu-
lations and other complications are rare. Gra ailure
occurs and varies with di erent populations and di -
erent gra types. It ranges rom 2% to 5%. T e rate o
deep venous thrombosis is approximately 1% to 1.5%,
iatrogenic neurovascular injury incidence is about 1%,
and postoperative intra-articular in ection has been
reported as low as 0.3% in a large cohort.
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Ur o l o gy
Joseph R. Sterbis
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 102
Nephrolithiasis

Peter L. Steinberg

A 35-year-old man presents to the emergency depart- 4. Which actors are predictive o ureteral stone
ment with one hour o severe right-sided ank pain. He passage?
is nauseated and vomited when the pain began. He has A. Stone size
no medical history and is not on any medications. He B. Stone location
has voided and his urinalysis shows 55 RBC per HPF C. Presence or absence o hydronephrosis
and no WBCs. D. A and B
E. A, B, and C
1. What is the single best test to diagnose a kidney or
ureteral stone? 5. Which medical condition(s) would you want
A. KUB to rule out in a recurrent calcium oxalate stone
B. Renal ultrasound ormer?
C. IVP (intravenous pyelogram) A. Hyperparathyroidism
D. Non-contrast computerized tomography (C ) B. Gout
scan o the abdomen and pelvis C. Cushings Syndrome
E. C scan o the abdomen and pelvis with and D. A and B
without IV contrast E. A, B, and C

2. Which o these actors would mandate immediate

decompression o the urinary tract with either a ANSWERS
ureteral stent or a percutaneous nephrostomy tube? 1. D. A non-contrast C (NCC ) o the abdomen in
A. Acute kidney injury pelvis is the single most accurate imaging test or a
B. Sepsis presumed rom the obstructed kidney renal or ureteral stone. T e sensitivity and speci c-
C. Uncontrollable pain ity o NCC are both in the high 90% range. Other
D. A, B, and C imaging modalities, such as renal ultrasound and
E. A and B kidney, ureter, and bladder (KUB) X-ray, can be used
to monitor a known stone, or are help ul i radiation
3. What is the most ef ective analgesia or kidney must be limited (pregnancy), but have a lower sensi-
stone colic in the emergency department? tivity and speci city than a NCC .
A. NSAIDs Renal ultrasound is most help ul i the patient has
B. ylenol hydronephrosis; however, 20% to 25% o patients
C. NSAIDs and IV opiates with a ureteral stone will not have hydronephrosis.
D. IV opiates Likewise, 20% to 30% o ureteral calculi will not
E. ylenol and IV opiates appear on a KUB. As a result, a NCC is the optimal
396 G EN ERAL S U RG ERY EXAM IN ATIO N AN D BO ARD REVI EW
test to assess unilateral ank pain in the emergency
department. A low dose protocol can be per ormed
in patients with a relatively low BMI, in an e ort to
reduce radiation exposure.
2. D. Uncontrollable pain, sepsis rom the renal unit
that is obstructed by a stone, and acute kidney injury
are the main reasons to per orm immediate decom-
pression o a renal unit. T e choice o a stent or a
percutaneous nephrostomy tube is based on local
experience, available personnel, the patients condi-
tion, and the chance o success ul placement o either
type o device.
3. C. T e combination o NSAIDs and IV opiates has
been shown to be superior to either agent alone in
the management o renal colic in the emergency
department.
ylenol has not been widely studied in the man-
agement o renal colic, and the pain is usually sub-
stantial, thus this would be a less desirable analgesic.
In addition, many patients with renal colic are vomit-
ing, and require parenteral analgesia and rapid anal-
gesia at that.
4. D. T e combination o stone location and stone size
allows estimation o ureteral stone passage rates. In
general, the smaller a ureteral stone is the higher
the chance o passage. Likewise, the more distal a
ureteral stone is the higher the chance o passage.
Smaller distal stones are more likely to pass than
larger proximal stones. T e presence or absence o
hydronephrosis has no bearing on whether or not a
stone will pass.
5. A. Hyperparathyoridism can cause urinary stones;
however, only 1% to 2% o kidney stone ormers have
hyperparathyroidism. Surgical management o the
parathyroid disease is of en curative o uture stone
ormation. An elevated blood calcium level, or even a
high normal blood calcium level, as well as recurrent
episodes o kidney stones should alert you to this as a
diagnostic possibility. A serum parathyroid hormone
(P H) level, as well as serum calcium and vitamin D
level should be obtained on these patients.
BIBLIOGRAPHY
EAU/AUA Nephrolithiasis Guideline Panel. 2007 guideline
or the management o ureteral calculi. J Urol. December
2007;178(6):241834.
Fulgham PF, Assimos DG, Pearle MS, Preminger GM. Clini-
cal e ectiveness protocols or imaging in the management
o ureteral calculous disease: AUA technology assessment.
J Urol. April 2013;189(4):120313.
Pearle MS, Gold arb DS, Assimos DG, Curhan G, Denu-
Ciocca CJ, et al. Medical management o kidney stones:
AUA guideline. J Urol. 2014;192(2):31624.
Sa dar B, Degutis LC, Landry K, Vedere SR, Moscovitz HC,
et al. Intravenous morphine plus ketorolac is superior to
either drug alone or treatment o acute renal colic. Ann
Emerg Med. August 2006;48(2):17381, 181.e1
Steinberg PL, Nangia AK, Curtis K. A standardized pain man-
agement protocol improves timeliness o analgesia among
emergency department patients with renal colic. Qual
Manag Health Care. January-March 2011;20(1):306.
 103
Bladder Cancer
Joseph R. Sterbis
A 64-year-old Caucasian male coal miner with a prior
20 pack per year smoking history, diabetes mellitus,
hypertension, and hyperlipidemia presents or evalua-
tion o urinary requency. A urinalysis demonstrates 2
WBC/high powered eld, 10 RBC/high powered eld,
and is negative or all other components. No red blood
cell casts or dysmorphic red blood cells are present on
urine microscopy.
1. Microscopic hematuria is de ned as which o the
ollowing?
A. Positive urine dipstick test
B. 1 cell/high powered eld
C. 3 cells/high powered eld
D. 5 cells/high powered eld
2. Which o the ollowing represents the complete
work-up o microscopic hematuria?
A. Cystoscopy, urine cytology
B. Renal ultrasound and bladder barbotage
C. Computerized tomography (C ) intravenous
pyelogram
D. Cystoscopy, C intravenous pyelogram
E. Urine cytology, urine culture
3. Cystoscopy revealed a large bladder tumor. A
transurethral biopsy o his tumor reveals muscle
invasive, high-grade bladder cancer. T e patient then
undergoes a radical cystectomy and ileal conduit.
Which o the ollowing electrolyte abnormalities is
expected af er urinary diversion with ileum?
A. Hypokalemic, hyperchloremic metabolic acidosis
B. Hypokalemic, hypochloremic metabolic alkalosis
C. Hyperkalemic, hypochloremic, hyponatremic
metabolic acidosis
D. Hypokalemic, hypernatremic metabolic alkalosis
E. None o the above
4. T e patient returns to clinic 18 months af er
surgery with recurrent gross asymptomatic
hematuria. Which o the ollowing sites is the
likely location or cancer recurrence?
A. Ileal conduit
B. Kidney
C. Psoas muscle
D. Lef renal pelvis
E. T yroid
ANSWERS
1. C. Asymptomatic microscopic hematuria (AMH)
is de ned as three or greater red blood cells per
high-powered eld on a clean catch midstream uri-
nary specimen in the absence o any other benign
cause. A positive dipstick does not de ne AMH and
microscopic examination o the urinary specimen is
mandatory or diagnosis. T e likelihood o a urologic
malignancy in the presence o microscopic hematu-
ria is approximately 10%.
2. D. T e complete work-up or hematuria includes
cystoscopy and C intravenous pyelogram. With this
evaluation strategy, the cause or hematuria is identi-
ed in 80% o cases. Patients with persistent hematu-
ria af er a negative initial evaluation warrant repeat
evaluation at 48 to 72 months. I the patient cannot
398 G EN ERAL S U RG ERY EXAM IN ATI O N AN D BO ARD REVIEW
obtain a C intravenous pyelogram, then alternative
acceptable imaging studies include intravenous pye-
logram, retrograde pyelography, or magnetic reso-
nance urography.
3. A. Hypokalemic, hyperchloremic metabolic aci-
dosis is the electrolyte abnormality present when
ileum as a urinary conduit. Hypochloremic acido-
sis occurs when ammonium chloride is absorbed
rom the urine into the blood stream. Hypokalemic,
hyperchloremic metabolic alkalosis occurs when the
stomach is used or urinary diversion and hydro-
chloric acid and potassium are lost in gastric secre-
tions. Hyperkalemic, hypochloremic, hyponatremic
metabolic acidosis are electrolyte derangements seen
when jejunum is used or urinary diversion. T e jeju-
num secretes sodium and chloride, while potassium
and hydrogen are absorbed.
4. D. T e patient has developed an upper urinary tract
tumor. According to SEER data, the relative risk
or upper urinary tract tumors or white men and
women was listed as 64.2% and 75.4% at or be ore
2 years; 44.3% and 40.5% at 2 to 5 years; 50.8% and
42.1% at 5 to 10 years; and 43.2% and 22.2% at more
than 10 years, respectively. Upper tract surveillance
af er a bladder tumor is necessary and is more likely
to occur with high-grade bladder cancer. It can be
per ormed with C urography.
BIBLIOGRAPHY
Castro JE, Ram MD. Electrolyte imbalance ollowing ileal uri-
nary diversion. Br J Urol. 1970;42:2932.
Douglas MD, McDougal WS. Use o Intestinal Segments
in Urinary Diversion. In: Wein AJ, Kavoussi LR, Novick
AC, Partin AW, Peters CA, eds. Campbell-Walsh Urology.
10th ed. Philadelphia: Saunders; 2007;241149.
Fontaine E, Barthelemy Y, Houlgatte A, et al. wenty-year
experience with jejunal conduits. Urology. 1997;50:20713.
Golimbu M, Morales P: Jejunal conduits: technique and com-
plications. J Urol. 1975;113:78795.
Gross eld GD, Litwin MS, Wol JS Jr, et al.: Evaluation o
asymptomatic microscopic hematuria in adults: T e Amer-
ican urological association best practice policyPart II.
Patient evaluation, cytology, voided markers, imaging, cys-
toscopy, nephrology evaluation and ollow-up. Urology.
2001;57:604.
Gross eld GD, Litwin MS, Wol JS Jr, et al. Evaluation o asymp-
tomatic microscopic hematuria in adults: T e American
urological association best practice policyPart I. De ni-
tion, prevalence and etiology. Urology. 2001;57:599.
Gross eld GD, Wol JS, Litwin MS, Hricak H, Shuler CL,
Agerter DC, Carroll PR. Asymptomatic Microscopic
Hematuria in Adults: Summary o the AUA best practice
policy recommendations. American Family Physician. 2001;
63(6). http://www.aa p.org/a p/2001/0315/p1145.html
Accessed May 7, 2011.
Kurzrock EA, Baskin LS, Kogan BA. Gatrocystoplasty: Long-
term ollow up. J Urol. 1998;160:21826.
Rabbani F, Perrotti M, Russo P, Herr HW. Upper-tract tumors
af er an initial diagnosis o bladder cancer: argument or
long-term surveillance. J Clin Oncol. 2001;19:94100.
Wright JL, Hotaling J, Porter MP. Predictors o upper tract
urothelial cell carcinoma af er primary bladder cancer: A
population based analysis. J Urol. 2009;181:10359.
Yun EJ, Meng MV, Carroll PR. Evaluation o the patient with
hematuria. Med Clin North Am. March 2004;88(2):32943.
 104
Renal umor

Joseph R. Sterbis

A 39-yr-old Caucasian male with a history o poorly B. Pulmonary metastases are not amenable to sur-
controlled hypertension, asthma, and hyperlipidemia gical resection.
obtains a C o his abdomen and pelvis to evaluate or C. Metastatectomy has been proven in randomized
vague right-sided abdominal pain and is ound to have control trials to improve disease- ree survival.
a right renal mass, measuring 8 6 7 cm in size. A D. Metastatectomy is contraindicated i there is
complete work-up reveals renal cell carcinoma with a more than 1 pulmonary lesion.
single lung metastasis. His glomerular ltration rate E. Metastatectomy will not improve his length o
(GFR) was calculated to be 30 mL/min. survival.
1. Decreased GFR (<60 mL/min) has been associated 4. T e patients amily history is signif cant or von
with which o the ollowing? Hippel-Lindau disease (VHL). He is tested or
A. Increased risk o death VHL and is ound to have VHL type 2B. He also
B. Decreased cardiovascular health reports having intermittent headaches, occasional
C. Increased risk o hospitalization palpitations, diaphoresis, which he attributed to
D. A and B only his poorly controlled hypertension. What is the
E. All o the above likely source o his prior symptoms?
2. Which o the ollowing is true o cytoreductive A. Retinal hemangioblastoma
nephrectomy? B. Cerebellar hemangioma
C. Pancreatic cysts
A. In rare cases it can lead to urther metastasis o
D. Pheochromocytoma
the tumor.
E. Epididymal cystadenoma
B. It can improve -cell unction against the pri-
mary tumor. 5. O the ollowing, which is the most reliable method
C. It can negatively impact the response to systemic to distinguish renal cell carcinoma rom an upper
cytokine therapy. tract urothelial tumor?
D. It has no impact on survival.
A. Retrograde urography
E. It cannot be per ormed in the setting o meta-
B. C urography
static disease.
C. Non-contrast renal C
3. Which o the ollowing is true o pulmonary D. Urine cytology
metastatectomy in this setting? E. Intravenous pyelography
A. Resection o limited metastatic disease has been
reported to be associated with long disease- ree
intervals and overall survival.
400 G EN ERAL S U RG ERY EXAM IN ATIO N AN D BO ARD REVI EW
ANSWERS
1. E. An independent, graded association has been
documented between a reduced estimated GFR
(starting at a GFR < 60 mL/min) and the risk o
death, cardiovascular events, and hospitalization. All
o the above are correct.
2. B. Cytoreductive nephrectomy preceding systemic
therapy is per ormed in the setting o advanced
metastatic disease and has been shown to lead
to spontaneous regression o the tumor. It is also
believed that -cell unction is inhibited by large
primary tumors. Overall survival has been shown to
improve when surgery is combined with cytokine
therapy.
3. A. Resection o limited metastatic disease has been
reported to be associated with long disease- ree
intervals and overall survival. Isolated pulmonary
metastases are lesions that are most commonly ame-
nable to resection with curative intent. T e overall
survival o patients undergoing complete resection o
limited metastatic disease was reported with median
5-year survival rates o 35% to 50%. No prospective
randomized trains have been per ormed to demon-
strate the avorable outcome attributed to resection
o solitary metastatic disease. T e current studies
may re ect patient selection bias, inherent di er-
ences in tumor biology, and natural history or other
con ounding actors. T e presence o additional pul-
monary lesions is not a de nitive contraindication to
metastatectomy.
4. D. Pheochromocytoma occurs in 10% to 17% o
patients with VHL. VHL type 2 di ers rom type 1
in that a ected amily members are at high risk to
develop pheochromocytomas. VHL type 2 is ur-
ther divided into types 2A, 2B, and 2C. Individuals
in amilies with VHL type 2A develop pheochromo-
cytomas but have a low risk or renal cell carcinoma
(RCC). T ose with VHL type 2B develop pheochro-
mocytomas and have a high risk or RCC.
5. B. Upper tract urothelial carcinoma (U -UC) is a
relatively uncommon orm o cancer arising rom
the urothelial lining o the renal pelvis and calyces.
U -UC o the renal pelvis is an aggressive tumor,
which may invade the renal parenchyma and mimic
primary RCC. Advanced RCC can also invade the
pelvicalyceal system. Distinguishing these primary
lesions rom each other can be di cult, and correct
diagnosis is needed to determine appropriate surgery
and medical treatment.
C urography easier to per orm than intravenous
pyelography and has a higher degree o accuracy in
detecting renal parenchymal lesions. T e sensitivity
or detecting upper tract malignant disease has been
reported to approach 100% with C urography. C
urography also has a speci city o 60% and a nega-
tive predictive value o 100%. Retrograde urography
has an accuracy o 75% in diagnosis o an upper tract
malignant neoplasm. Ureteroscopy is reserved or
situations when the diagnosis is unclear af er conven-
tional radiographic studies and or patients in whom
the treatment plan may be changed on the basis o
the ureteroscopic ndings, or example those who
may be amenable to endoscopic resection. Accuracy
estimates o the sensitivity o cytology range rom
about 20% or grade 1 tumors to 45% and 75% or
grade 2 and grade 3 tumors. Non-contrast C does
not allow or distinction between parenchymal and
urothelial lesions.
BIBLIOGRAPHY
Bloom HJ. Proceedings: Hormone-induced and spontane-
ous regression o metastatic renal cancer. Cancer. 1973;
32:106671.
Caoili EM, Cohan RH, Korobkin M, et al. Urinary tract abnor-
malities: Initial experience with multi-detector row C
urography. Radiology. 2002;222:353.
Flanigan RC, Salmon SE, Blumenstein BA, et al. Nephrectomy
ollowed by inter eron al a-2b compared with inter eron
al a-2b alone or metastatic renal-cell cancer. N Engl J Med.
2001;345:16559.
Friedel G, Hurtgen M, Penzenstadler M, et al. Resection o
pulmonary metastases rom renal cell carcinoma. Antican-
cer Res. 1999;19:15936.
Go AS, Chertow GM, Fan D, McCulloch CE, Hsu CY.
Chronic kidney disease and the risks o death, cardiovas-
cular events, and hospitalization. N Engl J Med. Septem-
ber 23, 2004;351(13):1296305. Erratum in: N Engl J Med.
2008;18(4):4.
Horton WA, Wong V, Eldridge R. Von Hippel-Lindau disease:
Clinical and pathological mani estations in nine amilies
with 50 a ected members. Arch Intern Med. 1976;136:769.
Levine E, Collins DL, Horton WA, et al. C screening o the
abdomen in von Hippel-Lindau disease. AJR Am J Roent-
genol. 1982;139:505.
Marcus SG, Choyke PL, Reiter R, et al. Regression o meta-
static renal cell carcinoma af er cytoreductive nephrec-
tomy. J Urol. 1993;150:4636.
Middleton AW, Jr. Indications or and results o nephrectomy
or metastatic renal cell carcinoma. Urol Clin North Am.
1980;7:7117.

Middleton RG. Surgery or metastatic renal cell carcinoma.
J Urol. 1967;97:9737.
Milestone B, Freidman AC, Seidmon EJ, et al. Staging o ure-
teral transitional cell carcinoma by C and MRI. Urology.
1990;36:346.
Murthy SC, Kim K, Rice W, et al. Can we predict long-term
survival af er pulmonary metastasectomy or renal cell
carcinoma? Ann T orac Surg. 2005;79:9961003.
Russo P, Synder M, Vickers A, et al. Cytoreductive nephrec-
tomy and nephrectomy/complete metastasectomy or met-
astatic renal cancer. Sci World J. 2007;7:76878.
Sella A, Swanson DA, Ro JY, et al. Surgery ollowing response
to inter eron-alpha-based therapy or residual renal cell
carcinoma. J Urol. 1993;149:1921; discussion 212.
C H AP TER 1 0 4 REN AL TU M O R 4 01
Snow RM, Schellhammer PF. Spontaneous regression
o metastatic renal cell carcinoma. Urology. 1982;20:
17781.
Walther MM, Yang JC, Pass HI, et al. Cytoreductive surgery
be ore high dose interleukin-2 based therapy in patients with
metastatic renal cell carcinoma. J Urol. 1997;158:16758.
Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA.
Chapter 49, Malignant Renal umors. In: Steven C. C.,
Brian R. L., eds. Campbell-Walsh Urology. 2012 ed. Phila-
delphia, PA: Elsevier Saunders; 2007;141374.
Zbar B, Kishida , Chen F, et al. Germline mutations in the
von Hippel-Lindau disease (VHL) gene in amilies rom
North America, Europe and Japan. Hum Mutat. 1996;8(4):
34857.
 105
esticular Lump

Joseph R. Sterbis

A 22-year-old Caucasion male presents to general sur- 4. Following the orchiectomy and staging imaging,
gery clinic or evaluation and treatment o a le inguinal which demonstrated a retroperitoneal mass,
hernia. During the physical examination, the hernia is the patient was treated with three cycles o BEP
identi ed, but a 3 cm le testicular mass is also noted. It is (Bleomycin, Etoposide, and Cisplatin). T is history
painless and rm. T e patient has not noted it previously. should prompt what concerns or subsequent
operative procedures?
1. T e initial radiographic assessment should consist
o what test? A. Bleomycin-induced pulmonary brosis should
prompt the anesthesia provider to limit FiO2 and
A. Scrotal magnetic resonance imaging (MRI)
be judicious in crystalloid and colloid adminis-
B. Pelvic and Scrotal computerized tomography
tration.
(C )
B. Etoposide-induced pulmonary brosis should
C. esticular ultrasound
prompt the anesthesia provider to limit FiO2 and
D. Any o the above
be judicious in crystalloid and colloid adminis-
2. Imaging has con rmed a testicular mass tration.
concerning or malignancy. Pending urologic C. Cisplatin-induced pulmonary brosis should
evaluation, a serum -hCG, Alpha-Fetoprotein prompt the anesthesia provider to limit FiO2 and
(AFP), and lactate dehydrogenase (LDH) tests be judicious in crystalloid and colloid adminis-
are ordered, all o which are signi cantly elevated tration.
above normal limits. Radical orchiectomy will be D. A and B
per ormed via which incision and will demonstrate E. B and C
which most likely pathology?
5. Following his course o chemotherapy, the patient
A. Scrotal incision; Seminoma
has a residual retroperitoneal mass, prompting
B. Scrotal incision; Non-seminoma
his urologist to per orm a retroperitoneal lymph
C. Inguinal incision; Seminoma
node dissection. T e patient should be counseled
D. Inguinal incision; Non-seminoma
regarding what potentially permanent genitou-
3. What is the primary landing zone or retro- rinary side ef ect as a result o this particular
peritoneal metastases in a le -sided testicular procedure?
germ cell tumor? A. Urinary retention
A. Paracaval lymph nodes B. Detrusor overactivity
B. Interaortocaval lymph nodes C. Reduced penile sensation
C. Para-aortic lymph nodes D. Erectile dys unction
D. Inguinal nodes E. Retrograde ejaculation

ANSWERS
1. C. T e imaging study o choice in testicular cancer
is a scrotal ultrasound. Classically, testicular cancer
will present as a painless testis mass, con rmed with
a corresponding hypoechoic lesion on ultrasound.
T e patient should have an accompanying Posterior-
Anterior (PA) and lateral chest radiograph. Once
a malignant diagnosis is con rmed, a C o the
abdomen and pelvis with IV and oral contrast will
complete the radiographic staging by assessing or
retroperitoneal metastases.
2. D. esticular cancer is managed with a radical
orchiectomy, which consists o a high ligation o the
spermatic cord at the level o the internal inguinal
ring per ormed via an inguinal incision. A long per-
manent suture is placed on the proximal end o the
spermatic cord be ore it is tucked into the internal
ring so that it may be later identi ed during a ret-
roperitoneal lymph node dissection. T e inguinal
incision allows or complete excision o the cord,
along with potential microscopic metastases, as well
as avoiding contamination o the scrotal lymphatics,
reducing rates o local recurrence. One meta-analysis
demonstrated a local recurrence rate o 2.9% or
those with scrotal violation vs. 0.4% with inguinal
incisions. Care should also be taken to avoid viola-
tion o the tunica vaginalis in order to reduce the risk
o local tumor recurrence.
T e presence o an elevated AFP indicates that
the patient will be treated as though he has a non-
seminomatous germ cell tumor as pure seminoma
will never produce AFP. Seminoma will express hCG
in approximately 15% o patients. Choriocarcinoma
and embryonal carcinoma, non-seminomatous sub-
types, can also produce hCG. Serum LDH is nonspe-
ci c, but it can correlate with disease volume.
3. C. Le -sided tumors predominantly metastasize
to the para-aortic lymph nodes, while right-sided
tumors will generally metastasize to the para-caval
and interaortocaval lymph nodes. In either case,
metastasis can occur to the opposite side, but such
crossing metastases are more common with right-
sided tumors. Generally, testis cancer metastasizes
in an organized, progressive manner, beginning with
the retroperitoneal lymph nodes. One exception is
choriocarcinoma, which can spread in a hematog-
enous manner.
C H AP TER 1 0 5 TEs Ti C u l AR l u m P 403
4. A. Bleomycin exposure can generate pulmonary
interstitial brosis. Patients treated with bleomy-
cin have experienced a potentially atal respiratory
distress syndrome ollowing general anesthesia.
Historically, it has been recommended to reduce
FiO 2 at the time o surgery, however, a retrospec-
tive study demonstrated that the most signi cant
actor predicting postoperative morbidity was over-
all perioperative uid balance. In this study, uid
balance was de ned as the combination o colloid
and crystalloid received in surgery, subtracting the
urine, blood, and nasogastric uids lost in the same
time rame.
In addition to uid resuscitation and oxygenation
concerns, one should consider obtaining preopera-
tive pulmonary unction tests prior to major surgical
procedures. T e same study cited above also dem-
onstrated that low preoperative orced vital capac-
ity also correlated with postoperative oxygenation
problems. Any preoperative assessment o a testicu-
lar cancer patient should determine his exposure
to bleomycin, with appropriate precautions taken i
necessary.
5. E. Retrograde ejaculation is a well-known side
ef ect rom retroperitoneal lymph node dissection
(RPLND). T e post-ganglionic sympathetic nerves
responsible or ejaculation ( 12-L3) are disrupted
during a RPLND. T is side ef ect may be avoided by
per orming a template RPLND in low stage disease
or by per orming a bilateral nerve-sparing RPLND.
In the ormer, the predictable metastatic pattern o
testicular germ cell tumors allow either the right or
le sympathetic nerves to be spared, thus preserving
ejaculation. Alternatively, a bilateral nodal dissection
can be per ormed, with care taken to preserve the
individual nerves along with the hypogastric plexus
anterior to the aorta, just below the origin o the
in erior mesenteric artery. With appropriate nerve
sparing, ejaculation can be preserved in nearly all
patients.
An additional complication o RPLND is that o
chylous ascities, due to lymphatic leakage. T is can
be prevented by meticulous attention to lympho-
stasis.
BIBLIOGRAPHY
Capelouto CC, et al. A review o scrotal violation in testicular
cancer: Is adjuvant local therapy necessary? J Urol. March
1995;153(3 Pt 2):9815.
404 G EN ERAl s u RG ERY EXAm i N ATi O N AN D BO ARD REVi EW

Donat SM, et al. Bleomycin associated pulmonary toxicity: Is
perioperative oxygen restriction necessary. J Urol. October
1998;160:134752.
Eggener SE, et al. Incidence o disease outside modi ed ret-
roperitoneal lymph node dissection templates in clinical
stage I or IIA nonseminomatous germ cell testicular can-
cer. J Urol. March 2007;177(3):93742.
Jules-Elysee K, et al. Bleomycin-induced pulmonary toxicity.
Clin Chest Med. 1990;11:1.
Klein EA. Open technique or nerve-sparing retroperito-
neal lymphadenectomy. Urology. January 2000;55(1):
1325.
NCCN Guidelines, esticular Cancer, 2014.
 106
raumatic Ureteral Injury
Ra aella DeRosa and Joseph R. Sterbis
A 30-year-old male is brought to the emergency room
ollowing a gunshot wound to the le lower quadrant.
He undergoes an exploratory laparotomy at which time
a colonic injury is identi ed, requiring resection o the
injured segment and a diverting colostomy. During ur-
ther assessment, a le ureteral transection is noted in
the mid-ureter.
1. T e patient is acidotic, hypothermic, and
hemodynamically abnormal. He has no other
apparent injuries. T e treatment o choice in this
setting is which o the ollowing?
A. ransureteroureterostomy
B. Ureteroureterostomy
C. Boari ap
D. Ligation o the ureteral stumps with permanent
suture
E. Psoas hitch with ureteral reimplant
2. His preoperative computerized tomography (C )
scan demonstrated a 5 mm lef lower pole renal
calculus. Which o the ollowing treatment options
is contraindicated?
A. ransureteroureterostomy
B. Ureteroureterostomy
C. Boari ap
D. Ligation o the ureteral stumps with permanent
suture
E. Psoas hitch with ureteral reimplant
3. Which o the ollowing considerations is true
when per orming an ureteroureterostomy?
A. A tension- ree anastomosis is not required.
B. Spatulating opposing ends o the ureteral seg-
ments can be done selectively.
C. Complete the anastomosis with ne, permanent
suture is required.
D. Placement o a double-J ureteral stent across the
anastomosis is recommended.
E. In the setting o a gunshot wound, a ureteroure-
terostomy cannot be done.
4. Which o the ollowing is true regarding
ureteroneocystostomy?
A. T e reimplant should be placed on the base o
the bladder.
B. A re uxing reimplant has a higher risk o stric-
ture.
C. T is is the treatment o choice or distal ureteral
injuries.
D. Stay sutures should not be placed in the ureter to
avoid tissue handling.
E. I a psoas hitch is required, the ipsilateral bladder
pedicle may need to be ligated to achieve su -
cient mobilization o the bladder.
5. Which o the ollowing is true about ureteral injury
due to external trauma rom gunshot wounds?
A. Ureteral injuries associated with external trauma
will always present with hematuria.
B. T e diagnosis is usually made by a C cystogram.
C. High velocity gunshot wounds (> 350 m/second)
can create a surrounding energy wave 30 to
40 times the missile diameter.
D. Injury rom missiles and bullets can be located
only along the path o tissue penetration.
406 G EN ERAL S U RG ERY EXAM I N ATIO N AN D BO ARD REVI EW
E. Blast injuries to the urinary drainage system will
usually present as an increase in output rom sur-
gically placed drains immediately (< 24 hours)
a er the surgery.
ANSWERS
1. D. I recognized at the time o surgery, surgical divi-
sion o the ureter and/or partial ureteral excision
should be managed based on the location and length
o injury. Options or repair include ipsilateral ure-
teroureterostomy, ureteral reimplantation with or
without a psoas hitch, trans ureteroureterostomy. In
occasions when the patient is unstable, the ureter can
be ligated with sutures, a nephrostomy tube is placed,
and reconstruction can occur within the next 48 to
72 hours. I the patient is hemodynamically unstable,
then damage control is recommended and delayed
ureteral repair can be per ormed.
2. A. ransureteroureterotstomy places the contralat-
eral renal unit at risk and is contraindicated in
patients with a prior history o urinary stone disease.
Both upper tracts are at risk o there is any problem
with one side. T e other reconstructive surgeries
can be implemented in the setting o known stone
disease.
3. C. T e use o permanent sutures within the urinary
tract is a nidus or stone ormation. T e proximal and
distal ends o the ureters should be spatulated and
sewn together in a tension- ree ashion with absorb-
able mono lament suture. A stent should be placed
across the watertight anastomosis. Contusions or
damaged areas o the ureter need to be debrided
until the edges bleed prior to per orming ureteral
anastomoses.
4. D. Short de ects involving the distal ureter should
be repaired with ureteroneocystostomy. Non-re ux-
ing ureteral implants have a higher risk o stricture
than re uxing ureteral implants. Re uxing anasto-
moses show no increase in complications related to
urine re ux. T e principles o repair include spatula-
tion, lack o tension, stenting, postoperative drainage,
and a watertight anastomosis with ne non-reactive
absorbable suture. T e contralateral bladder pedicle
can be ligated when per orming a psoas hitch using
in order to provide enough mobilization to per orm
a ureteroneocystostomy. Stay suture can improve tis-
sue handling and preserve the blood supply to the
ureter. Re-implated ureters are usually placed at the
dome o the bladder.
5. C. T e missile or bullet can tumble during penetra-
tion and cause damage to the surrounding tissues at
a signi cant distance rom its path. Hematuria is not
always present a er ureteral injury. riphasic C can
be used to evaluate tissue trauma and or ureteral
injury. C cystogram will usually identi y a bladder
injury. High velocity bullets or missiles can create an
energy wave that penetrates and injures distant tis-
sues. Damage to the ureters can present 3 to 5 days
a er injury as increased drainage rom the surgically
placed drains. T is uid can be sent to pathology or
a creatinine level.
BIBLIOGRAPHY
Al-Ali M, Haddad L. T e late treatment o 63 overlooked
or complicated ureteral missile injuries: the promise o
nephrostomy and role o autotransplantation. J Urol. 1996;
156:191821.
Carver B, Bozeman C, Venable D. Ureteral injury due to pen-
etrating trauma. South Med J. 2004;97:4624.
Elliot S, McAninch JW. Ureteral injuries: External and iatro-
genic. Urol Clin North Am. 2006;33:5566.
Fugita OE, Kavoussi L. Laparoscopic ureteral reimplantation
or ureteral lesion secondary to transvaginal ultrasonogra-
phy or oocyte retrieval. Urology. 2001;58:281.
Ghali A, El Malik E, Ibrahim A, et al. Ureteric injuries: Diag-
nosis, management, and outcome. J Trauma. 1999;46:
1508.
Iwaszko MR, Krambeck AE, Chow GK, Gettman M . rans-
ureteroureterostomy revisited: Long-term surgical out-
comes. J Urol. March 2010;183(3):10559.
Kristjnsson A, Mnsson W. Re uxing or nonre uxing ure-
teric anastomosis. BJU Int. November 1999;84(8):905
10.
Kunkle D, Kansas B, Pathak A, et al. Delayed diagnosis o trau-
matic ureteral injuries. J Urol. 2006;176:25037.
Medina D, Lavery R, Ross S, Livingston D. Ureteral trauma:
Preoperative studies neither predict injury nor prevent
missed injuries. J Am Coll Surg. 1998;186:6414.
Minervini A, Boni G, Salinitri G, et al. Evaluation o renal unc-
tion and upper urinary tract morphology in the ileal ortho-
topic neobladder with no antire ux mechanism. J Urol.
2005;173(1):1447.
Modi P, Goel R, Dodiya S: Laparoscopic ureteroneocys-
tostomy or distal ureteral injuries. Urology. 2005;66:
751.
Noble IG, Lee K , Mundy AR. ransuretero-ureterostomy: A
review o 253 cases. Br J Urol. January 1997;79(1):203.
Palmer JK, Benson GS, Corriere JN, Jr. Diagnosis and initial
management o urological injuries associated with 200
consecutive pelvic ractures. J Urol. 1983;130:7124.

Perez-Bray eld M, Keane , Krishnan A, et al. Gunshot
wounds to the ureter: A 40-year experience at Grady
Memorial Hospital. J Urol. 2001;166:11921.
Reddy PK, Evans RM. Laparoscopic ureteroneocystostomy.
J Urol. 1994;152:2057.
Schimp MO, Wagner JR. Robot-assisted laparoscopic boari
ap ureteral reimplantation. J Endourol. 2008;22:2691.
Velmahos G, Degiannis E. T e management o urinary tract
injuries a er gunshot wounds o the anterior and posterior
abdomen. Injury. 1997;28:5358.
C H AP TER 1 0 6 TRAU MATIC U RETERAL IN j U RY 407
Wessells H, Deirmenjian J, McAninch J. Preservation o renal
unction a er reconstruction or trauma: Quantitative
assessment with radionuclide scintigraphy. J Urol. 1997;
157:15836.
Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA.
Chapter 42, Upper Urinary ract rauma. In: Richard AS,
Leon RD, eds. Campbell-Walsh Urology. 2012 ed. Philadel-
phia, PA: Elsevier Saunders; 2007;116992.
Wiesner C, T urof JW. echniques or uretero-intestinal
reimplantation. Curr Opin Urol. 2004;14(6):3515.
 107
Prostate Cancer
Joseph R. Sterbis
A 58-yr-old male is diagnosed in urology clinic with
clinical 2a Gleason 3 + 4 = 7 prostate cancer. His
serum PSA is 4.2. He has a history o hypertension and
no prior surgical history. He has no prior history o
radiation or chemotherapy administration.
1. Which treatment options should NO be recom-
mended to the patient?
A. Radical prostatectomy with bilateral pelvic
lymph node dissection
B. External beam radiation therapy
C. Brachytherapy seed implants
D. Active surveillance
2. T e patient elects or a radical prostatectomy with
bilateral pelvic lymph node dissection. During the
pelvic lymph node dissection, the le obturator
nerve is accidentally divided with metzenbaum
scissors. It is recognized immediately. How do you
address this complication?
A. Because the division was done sharply, leave
the two ends ree ollowing completion o the
lymphadenectomy.
B. Reapproximate the two ends with ne, perma-
nent suture.
C. Per orm a nerve gra , approximating the two
ends.
D. All o the above
E. A or C
3. During the apical prostatic dissection, a small 1
cm ull thickness rectal injury is incurred. Which
o the ollowing is the best course o action at this
time?
A. Omental ap coverage ollowing primary repair
B. Resection o the injured rectum, ollowed by
primary anastomosis
C. Resection o the injured rectum, primary anasto-
mosis and diverting ileostomy
D. Diverting colostomy a er resection even in a
patient without prior radiation therapy
E. Double layer, air-tight closure o the rectal injury
4. Four months later, the patient is scheduled or a
laparoscopic cholecystectomy. T e operating room
nurse has dif culty placing a oley catheter. What
is the most likely source or this dif culty?
A. Anastomotic contracture at the bladder neck
B. Prostate cancer recurrence at the bladder neck
C. Urethral stricture
D. Rectourethral stula
5. T e patient experiences a disease recurrence and is
initiated on androgen deprivation therapy (AD ).
Which o the ollowing is true regarding this
treatment?
A. T e patient is at reduced risk or cardiac
morbidity.
B. T e patient is at increased risk or loss o lean
muscle.
C. T e patient is at reduced risk or osteoporosis.
D. T e patient is at increased risk or loss o body
at.
ANSWERS
1. D. Active surveillance is appropriate or men
with low risk prostate cancer, de ned as having

organ-con ned pathology, < 0.2 mL, a Gleason sum
less than or equal to 6, and no Gleason grade 4 or 5
in the biopsy specimen.
2. B. I the obturator nerve is accidentally divided, it
should be reanastamosed with ne, non-absorbable
sutures. T e patient can make a ull unctional
recovery.
3. D. Rectal injury is a serious intraoperative compli-
cation. I a rectal injury occurs, the prostatectomy
should be completed. Small injuries that are less than
50% o the circum erence o the rectum can be treated
without resection. T e rectum can be closed primar-
ily, and a piece o omentum should be placed between
the rectal closure and the vesicourethral anastomosis
to reduce the incidence o rectourethral stula. T e
rectal de ect should be closed in two layers and the
wound copiously irrigated with antibiotic solution. I
the patient has had radiation therapy prior to surgery,
a diverting colostomy should be per ormed.
4. A. wo to ve percent o patients develop a blad-
der neck contracture approximately 6 to 12 weeks
a er an open prostatectomy. T e initial management
includes dilation with urethral sounds or a direct
vision incision o the bladder neck.
5. B. General complications o androgen ablation
include osteoporosis, hot ashes, and decline in
cognitive unction, increased cardiovascular mor-
bidity and mortality, and changes in body habitus.
Bone mineral density can decrease, and the longer
the patient remains on AD , the greater the risk o
racture. AD has been linked to cognitive decline
in men with prostate cancer. Men treated with AD
C H AP TER 1 0 7 P Ro s TATE C An C ER 409
have demonstrated a loss o muscle mass and increase
in percentage o body at. AD can adversely a ect
body habitus, glucose metabolism, lipid pro les, and
increase cardiovascular morbidity and mortality.
BIBLIOGRAPHY
Borland RN, Walsh PC. T e management o rectal injury dur-
ing radical retropubic prostatectomy. J Urol. 1992;147:905
907.
Daniell HW, Dunn SR, Ferguson DW, et al. Progressive osteo-
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cancer. J Urol. 2000;163:1816.
Epstein JI, Walsh PC, Carmichael M, et al. Pathologic and clin-
ical ndings to predict tumor extent o nonpalpable (stage
1c) prostate cancer. JAMA. 1994;271:36874.
Krupski L, Smith MR, Lee WC, et al. Natural history o bone
complications in men with prostate carcinoma initiating
androgen deprivation therapy. Cancer. 2004;101:5419.
Nelson CJ, Lee JS, Gamboa MC, Roth AJ. Cognitive e ects
o hormone therapy in men with prostate cancer. Cancer.
2008;113:1097106.
Saigal CS, Gore JL, Krupski L, et al. Androgen deprivation
therapy increases cardiovascular morbidity in men with
prostate cancer. Cancer. 2007;110:14931500.
Spaliviero M, Steinberg AP, et al. Laparoscopic injury and
repair o obturator nerve during radical prostatectomy.
Urology. November 2004;64(5):1030.
ubaro A, Carter S, et al. A prospective study o the sa ety
and ef cacy o suprapubic transvesical prostatectomy in
patients with benign prostatic hyperplasia. J Urol. 2001:
166(1):1726.
Van Londen G, Levy ME, Perera S, et al. Body composition
changes during androgen deprivation therapy or prostate
cancer: A 2-year prospective study. Crit Rev Oncol/Hematol.
2008;68:1727.
Varkarakis I, Kyriakakis Z, et al. Long-term results o open
transvesical prostatectomy rom a contemporary series o
patients. Urology. 2004;64(2):306310.
Vasilev SE. Obturator nerve injury: a review o management
options. Gynecol Oncol. 1994 May;53(2):1525.
This page intentionally left blank

A American T yroid Association (A A), 216, 218
Abbe ap, or lip de ects, 41, 4243
Abdominal aortic aneurysm (AAA), 331332
abdominal ultrasound or, 331, 332
endovascular repair (EVAR) vs. open repair,
331, 332
natural history o , 332
repair o , indications or, 331, 332
risk actors with ormation o , 331
screening or, 331332
Abdominal pain, a er laparoscopic gastric
bypass, 103105
Abdominal wall reconstruction, 6163
Abdominal wound, 253, 254
FAS examination in, 253, 254
Accessory spleens, 150151, 152
Achalasia, 7981
manometry or diagnosis o , 79, 80
treatment or, 21, 23, 79, 8081
Acute atty liver o pregnancy (AFLP), 133, 134
and HELLP syndrome, 134
Acute mesenteric ischemia (AMI), 156, 158
Acute respiratory distress syndrome (ARDS),
292, 294
Acute subdural hematoma (aSDH), 266, 271
Acute tubular necrosis (A N), 322
Adenoid cystic carcinomas, 222
Adenomatous polyposis syndromes, 172
Adrenal cortical carcinoma, 210
Adrenal gland tumors, 209211
Adrenal mass, 210
laparoscopic adrenalectomy or, 211
percutaneous biopsy o , 210
pheochromocytoma evaluation or, 210
treatment o , 209, 210, 211
Adrenocortical carcinoma, 211
Adrenocorticotropic hormone (AC H), 57, 209
Advanced cardiac li e support (ACLS), 246
Advanced directives, 37, 38
oral, 38
Advanced trauma li e support (A LS), 246
Aganglionic bowel, 237
Air-contrast barium enema (ACBE), 173
Airway re, 11, 12
Airway pressure release ventilation (APRV),
292
Aldosterone, 9, 210
Alpha-adrenergic blockade, 210. See also
Pheochromocytoma
side e ects o , 210
American Society o Colon and Rectal
Surgeons (ASCRS), 180, 181
Index
Anal stula, treatment o , 186, 187
Anastrazole, 193
Ancrod, 306
Androgen deprivation therapy (AD ), 408,
409
Aneurysmal rupture, 274
Ankle-brachial index, 254
Anorectal manometry, 237
Anterior cruciate ligament (ACL) tear
complication a er surgical reconstruction,
388, 391
gra s or ACL reconstruction, 390391
Lachman test or, 388, 390
meniscal tears with, 388, 390
treatment or, 388, 390
Anterior drawer test, 390
Anteroposterior compression (APC III)
racture, 262, 263
Anthracycline, 200
Antidiuretic hormone (ADH), 280
Anus-rectal cancer, 183185
Aortic trocar per oration, 1920
APACHE score, 294
Apley compression test, 390
Appendicitis, 167169
clinical mani estations, 167, 168169
con rmatory imaging in, 167, 169
laparoscopic appendectomy or, 168, 169
overview, 168
and pregnancy test, 167, 168
surgical management or, 167, 169
Argon beam coagulation, and venous
embolism, 1315
cautions o manu acturer, 1415
management in, 13, 15
risk actors or, 13, 14
Arterial pressure index, 254
Arteriovenous (AV) stula, 334336
distal revascularization and interval ligation
(DRIL) procedure, 335336
in ected AV stula gra and management,
335, 336
placement in contralateral arm, 334, 335
temporary dialysis access, 334, 335
Ascites
cirrhosis and, 141
pericentesis in, 140, 141
Aspirin, or vertebral artery injuries, 257
Asymptomatic microscopic hematuria (AMH),
397
Atracurium, 7
411
Attenuated FAP (AFAP), 173
Auriculotemporal nerve, 223
Autologous tissue reconstruction, 202, 205.
See also Breast reconstruction
disadvantage o , 205
Axillary lymph node dissection, 200
Azathioprine, 322, 323
B
Babinski sign, 269
Back pain, 371373
disc herniation and, 371, 372
evaluation o , 371, 372
lumbar herniated discs, 371, 372373
microdiscectomy and complications, 372,
373
Bariatric procedures, 109, 110. See also Bariatric
surgery
duodenal switch, 109, 110
malabsorptive e ects, 110
nutrition complications, 115116
restrictive e ects, 109
Bariatric surgery
candidacy or revision, 117, 118
ideal candidates or, 117118
revisional surgery, 117, 118119
Barretts esophagus without dysplasia, 95, 96
Basal cell carcinoma, 42, 43
treatment or, 41, 42
Base de cit, 293
Becks riad, 254
Beckwith-Wiedemann syndrome, 239, 240
Benign prostatic hyperplasia (BPH), 315
Bethesda criteria, 185
Bevacizumab, 356
Bilateral neck exploration, 212
Bi-layer mesh repair, 72
Bile microscopy, 128
Biliary colic, 127129
and gallbladder cancer, 127, 128
medical therapy or, 127, 128
open cholecystectomy in, 128
repeat right upper quadrant ultrasound in,
127, 128
ultrasound in, 127, 128
Biliary disease, in pregnancy, 133136
Biologic targeted therapies, or ovarian cancer,
356
Bipolar energy devices, 30
BIRADS 4 lesion, 191, 192
Bladder cancer, 397398
Bladder rupture, 312
412 In d e x
Blast injuries, 246, 247248
primary, 246, 247248
quaternary, 248
secondary, 248
tertiary, 248
Bleomycin, 229
Bleomycin-induced pulmonary brosis, 402,
403
Blood products and trans usion, 304306
Blunt trauma, 263
Bochdalek hernias, 78
Body sur ace area (BSA), 298
Brain cell swelling, 273
Brain injury, treatment o , 260
Branchial cle cysts, 227, 228
Branchial cysts and stulas, 229
BRCA1 gene, 191, 192
BRCA2 mutations, 192
Breast cancer, 192
chemotherapy or, 193
conserving surgery, 193
core biopsy o , 192
eatures o , 192
and hereditary syndromes, 192
radiation therapy or, 193
risk actors or, 192
stages, 205
ultrasound or, 192
Breast conservation therapy (BC ), 195, 196
Breast mass, 191194
Breast reconstruction, 202205
autologous/synthetic, 204
autologous tissue reconstruction, 202, 205
sentinel lymph node biopsy, 202
and tissue expanders, 205
Burns and smoke inhalation, 297299
chemical injury and, 298
rule o nine, 298
Burr-hole drainage, 270, 275
C causes o , 130131
Cadaver allogra , 299
Calcaneus ractures, 377379
C scan in, 377, 378379
delayed open reduction and internal xation
in, 378, 379
displaced, intra-articular racture, treatment
o , 378, 379
and lumbar spine injuries, 377, 378
mechanism o injury or, 378
operative treatment, outcomes o , 378, 379
plain x-rays o oot in, 378
splint placement and elevation, 378, 379
Cantholysis, steps or, 285
Capacitive coupling, monopolar instruments,
30
Carbon monoxide poisoning, 298
Carcinoembryonic antigen (CEA), 183
Carcinoid crisis, 161
Carcinoid tumors, 160162
Chromogranin A levels in, 161
requent location o , 161
metastases, 161, 162
surgery or metastatic disease, 161, 162
urine 5-HIAA levels in, 161162
Carotid endarterectomy (CEA), 330
emergent, 330
Carotid occlusion, 329330
atropine during surgery, 329, 330
carotid endarterectomy in, 329, 330
crescendo transient ischemic attacks ( IA)
and, 330
C angiography (C A) in, 329, 330
emergent carotid endarterectomy, 330
neurological events in recovery room and
re-operation, 329, 330
string sign, and urgent carotid
endarterectomy, 329, 330
Carotid sinus, 330
Catheter cerebral angiography, 269
Catheter-related bloodstream in ections
(CR-BSI), 303
Cauda equina syndrome (CES), 372
Ce azolin, 284
Cellulitis, 223
Central venous pressure (CVP), 291
Cerebral blood ow, 273
Cerebral contusions, 273
Cerebral per usion pressure (CPP), 260
Cerebral salt wasting (CSW), 280
Cerebral vasospasm, 269
Cerebrospinal uid (CSF), 265
dural injury with persistent, 265
post-traumatic, 266, 271
Cerebro vascular resistance (CVR), 273
Cervical spine clearance, 256257
Charcot de ormity, 308
CHARGE syndrome, 239, 240
Chemical injury, o eyes, 282, 283
uorescein exam, 286
Chest trauma
and pulmonary complications, 290
and tracheobronchial injury, 289, 290
urgent bronchoscopy in, 289, 290
Cholangitis, 130132
gallstones and, 130
MRCP or, 130, 131
pathophysiology o , 130, 131
in pregnancy, 136
septic, 130, 131132
Cholecystectomy, 128, 220
laparoscopic, 21, 22
Cholecystitis, in pregnancy, 133136
and cholecystectomy, 136
ERCP with sphincterotomy in, 134,
136
gangrenous cholecystitis, 135
imaging or, 133, 134135
management o , 135136
Cholecystokinin stimulated cholescintigraphy,
128
Cholelithiasis. See Biliary colic
Cholestasis, 302
Chronic subdural hematoma (CSDH), 270
age and, 270, 275
bilateral e usion and, 270, 275
development o , 270
recurrence rate o , 270
treatment o , 270, 275
Chronic venous insu ciency (CVI), 341, 343,
344
medical management, 343, 345
surgical management, 343, 345
Chvosteks sign, 212
Cirrhosis
abdominal wall hernia ormation, actors
or, 64, 65
elective repair o hernias in, 64, 65
perioperative mortality risk, 64, 65
preoperative anemia and postoperative
complications, 64, 65
Cistatracurium, 7
Clean intermittent catheterization (CIC), 314
Clevidipine, 9
Clindamycin, 309, 310
Clostridium dif cile in ection, 292, 293
Colectomies, robotic-assisted, 29
Colon cancer, 171175, 183185
colonoscopy in, 171, 173, 183, 184
C scan in, 171, 173
Enhanced Recovery A er Surgery (ERAS)
protocols, 172, 174175
hereditary syndromes o gastrointestinal
tract and, 172173
laparoscopic colonic resection or, 171172,
174
Colon neoplasm, 180
Colonoscopy, 180
in cancer diagnosis, 184
Colorectal metastatic cancer, neoadjuvant
chemotherapy or, 138, 139
Comedonecrosis, 196
Compressive therapy, or lymphedema, 340, 341
Computed tomographic (C ) scan
abdomen and pelvis with IV contrast, 312
colorectal cancer, 184
head, 265, 267
kni e wounds, 249, 251
multiple hemorrhagic brain contusions, 267
right rontoparietal chronic subdural
hematoma, 269
sigmoid diverticulitis, 179, 180
transmediastinal gunshot wound, 289
Congenital muscular torticollis, 230
Conns syndrome, 10
Contrast esophagography, 251
Contrast esophagram, or dysphagia, 79, 80
Coopers ligament repair, 71, 72
CORAL trial, 10
Core needle biopsy, 222
Corticosteroids, in subdural hematoma
treatment, 275
Count ngers (CF), 286
Cowden syndrome (CS), 173, 192
CPAP, in obstructive sleep apnea, 5, 7
Cranioplasty, 270
Craniostomy, twist drill, 270, 275
Craniotomy, 270, 275
Crepitus, a er mediastinal dissection, 29
Cricoid cartilage, 249, 251
Crohns disease, 176178
approach or surgical management, 176,
177
classi cation o , 177

colorectal cancer in, risk o , 177178
in iximab in, 176, 177
non-operative management, 176, 177
operative intervention or, 176, 177
and perirectal abscesses, 187
C angiography (C A), 249, 288
and 3-dimensional reconstruction imaging,
274
o kni e wounds, 249
C colonography, 184
Cushings syndrome, 10, 209, 210
causes o , 210
signs and symptoms o , 210
Cushings triad, 273
Cutaneous lichen amyloidosis, 216
Cyanide poisoning, 298
nitroprusside and, 8, 9
Cyclophilin protein, 322
cyclosporin binds, 322, 323
Cyclophosphamide, 200
Cystic hygromas. See Lymphatic mal ormation
Cytomegalovirus (CMV), 306
Cytoreduction, 355
Cytoreductive nephrectomy, 399, 400
Cytotoxic brain edema, 274
D hCG levels in, 358, 359360
Damage control resuscitation (DCR), 246, 247
Damage control surgery (DCS), 245, 247
Decubitus ulcers, 4446
Deep in erior epigastric per orator (DIEP) ap,
204, 205
Deep tendon re exes (D R), 266
Deep venous thrombosis, 218
Dermato brosarcoma protuberans (DFSP), 52
Dermoid cysts, 228
Dexamethasone, 260
suppression test, 210
Diabetes insipidus (DI), 280
nephrogenic, 280
neurogenic, 280
treatment o , 280281
Di use esophageal spasm (DES), 81
Di use large B-cell lymphoma (DLBCL),
gastric, 89, 9192
Di use post traumatic intracerebral
hemorrhage, 273
Di usion tensor imaging (D I), 271
Discectomy, 372, 373
Disc herniation, 371, 372
Diverticulitis, 179181
colon resection in, 179
complicated
treatment o , 179, 180181
elective resection in, 180
sigmoid
diagnosis o , 180
treatment o , 179, 180
DNA mismatch repair genes, 185
Doctrine o parens patriae, 36
Dopamine, 293
Doppler ultrasound, in vessel patency
evaluation, 321
Double e ect, principle o , 38
Doxorubicin, 200
4 Ds, 220
Ductal adenocarcinoma, 192
Ductal carcinoma in situ (DCIS), 191, 192,
195198, 205
imaging in, 195
patient, mortality risk in, 196
risk actors or, 196
vs. LCIS, 198
Duodenal per oration, incidence o , 234
Duodenal switch procedure, 109, 110
anatomy, 110111
bene ts o , 109, 111112
candidacy or, 110
complications o , 109110, 112
and gastric bypass, 110111
malabsorptive e ects, 109, 110
perioperative complications, and emergent
surgical exploration, 110, 112
Duodenal ulcers, 217
Durable power o attorney, 38
E Estrogen receptor-positive (ER+) tumors, 193
Ectopic cordis, 239
Ectopic pregnancy, 358361
active, 360
DEME ER trial, 361
implantation sites, 360
medical treatment with methotrexate, 358,
360
recurrent, rate o , 359, 361
risk actors or, 359
salpingectomy or, 358, 360361
surgical management, 360361
trans-vaginal ultrasonography in, 358, 359
Ectopic thyroid tissue, 228
Elbow injuries, in children, 384385
Electrosurgery
bipolar instrumentation, 30
coagulation mode, 30
cut mode, 30
monopolar instruments, 28, 30
Elevated intracranial pressure, management o ,
259261
End o li e care, 3738
advance directives in, 37, 38
decision making in, 3738
li e-sustaining medical treatment, 37, 38
Endometriosis, 366368
with bowel involvement, 366367, 368
deep in ltrative lesions (DIE), 367
de nition o , 367
endometriomas, 367
laparoscopic evaluation o , 366, 367
medical therapy, 367
presentations, 366, 367
site o intestinal, 366, 367
super cial lesions, 367
surgical treatment or, 366, 368
Endorectal ultrasound, 184
Endoscopic ne needle aspiration biopsy, 219
EndoWrist technology, 26
Enhanced Recovery A er Surgery (ERAS)
protocols, or colon surgery, 172,
174175
In d e x 413
Enteral nutrition, 301, 302
Epidural hematoma (EDH), 266
causes o , 271
cranial, 266
complications and outcome o , 267,
272273
diagnosis o , 267, 272
management o , 267, 272
delayed, 273
occurrence o , 271
Epirubicin, 200
Epstein-Barr virus (EBV), 321
Erysipelas, 309
Escharotomy, 297, 299
Esophageal per oration
gastrogra n esophagography in, 95, 96
le posteriolateral thoracotomy in, 95, 9697
non-operative management in, 95, 96
operative management in, 96
Esophagogastroduodenoscopy (EGD), 79, 80,
128, 250
European Organisation or Research and
reatment o Cancer (EOR C), 196
Evaluation o Genomic Applications in Practice
and Prevention (EGAPP), 185
External ori ces, o stula track, 187. See also
Perirectal abscess
Extra-corporeal membrane oxygenation
(ECMO), 292
Extracorporeal shockwave lithotripsy (ESWL),
128
Extraordinary care, and ordinary care, 38
Extremity sarcomas, 50, 51
histologic subtypes, 50, 51
incisional biopsy or, 51
local recurrence a er treatment or, 52
radiation therapy, 50, 52
site o metastasis, 51
surgical management o , 50, 5152
Eye exam
primary survey, 286
secondary survey, 286
F
Facial hemihypoplasia, 230
Familial adenomatous polyposis (FAP), 173,
185
Familial medullary thyroid carcinoma (FM C),
218
Fecal immunochemical testing (FI ), 173
Feculent peritonitis, 181. See also Diverticulitis
Femoral hernia, 68, 70, 7172
McVay repair or, 71, 72
preperitoneal repair technique or, 71, 72
recurrence o , etiology or, 71, 72
Femoral-saphenous AV stula, 335
Fenoldapam, 9
Fibrin glue, 186, 187
Filariasis, 341
Fine-needle aspiration (FNA), 192, 215, 216,
221, 229
Fires, operating room, 1112
First rib resection, complications o , 348, 349
Fistula-in-ano, 187
4 14 In d e x
Fistula, occurrence o , 187
Fistulotomy, conventional, 187
Fitzhugh-Curtis syndrome, 363
Fluid-attenuated inversion recovery (FLAIR),
269
Fluid restriction, 279
5- uorouracil, 200
Foam sclerotherapy, 345346
Focused assessment with sonography or
trauma (FAS ), 253, 254, 312
Foley trauma, 314315
Freys syndrome, 223
Fulminant hepatic ailure, 325
Furosemide, 273
G Gastroschisis, 239240
Gail Model, 192
Gallbladder cancer (GBC), 123125
anatomical resection vs. wedge resection,
124, 125
MDC ndings, 123, 124125
peritoneal involvement with, 125
prognosis o , 125
radical cholecystectomy or, 123, 125
risk actor or, 123, 124
Ganglion cells, 237
Gastric bypass and bowel obstruction, 103105
Gastric cancer, 8285
CLASSIC trial, 84
di use, 84
Intergroup rial 0116, 84
intestinal type, 84
Irishs node and, 82, 85
neoadjuvant therapy or, 82, 84
preoperative locoregional staging or, EUS
or, 82, 83
Stage III, treatment or, 82, 8485
Gastric lymphoid tumors, 8992
Ann Arbor Staging System, 90
endoscopic ultrasound and, 90
high-grade, treatment strategy or, 89, 9192
Lugano Staging System, 90
staging o , 89, 90
stomach preserving treatment strategies
or, 90
surgical intervention or, 89, 90
Gastric MAL lymphomas
H. pylori eradication therapy or, 89, 91
radiation therapy or, 89, 91
Gastric ulcers, 83
biopsy o , 82, 83
giant, 83
Gastrinoma, 219
localization o , 219
Gastrinoma triangle, 219
Gastroduodenal ulcer, per orated
chest x-ray or diagnosis o , 156, 157
H. pylori in ection and, 157158
nonoperative management, 156, 157
stimulant drug abuse and, 156, 157
surgical management, 156, 157
Gastroesophageal re ux disease, 9497
esophagogastroduodenoscopy in, 94, 9596
uid collection post-operative, 95, 96
Nissen undoplication in, 95, 96
proton pump inhibitor in, 94, 9596 Hepatic steatosis, 302
and sliding hiatal hernia, 9495, 96 Hepatitis C virus (HCV), 324, 325
Gastrogra n esophagography, 95, 96 Hepatobiliary (HIDA) scan, 128
Gastrointestinal stromal tumors (GIS ), 52, Hepatocellular carcinoma (HCC), 324
8688 Hereditary nonpolyposis colon cancer
diagnosis o , 86, 87 (HNPCC), 185, 192, 354
KI positive, 86, 87 Hiatal hernia, 77
metastatic, 88 endoscopy or, 7778
preoperative therapy with imatinib in, 86, etiology o , 77, 78
8788 phrenoesophageal ligament weakening and,
prognostic actors in, 88 77, 78
recurrence ree survival in, 87, 88 slipped Nissen, 77, 78
solitary, 87, 88 types o , 77, 78
Gastrointestinal tract, hereditary syndromes o , Hickman catheter, 301, 303
172173 High microsatellite instability (MSI-H), 185
Hirschprungs associated enterocolitis (HEC),
management o newborn with, 239, 240 238
and omphalocele, 240 risk actors or, 238
Genitourinary trauma, 312313 Hirschsprungs disease, 216, 236238
Gentamicin, 284 constipation and, 237
Glasgow coma scale (GCS), 259, 262, 265 diagnosis o , 237
components o , 259260 multiple intraoperative biopsies or, 238
trauma bay with, 279 surgery or, 237, 238
Glomerular ltration rate (GFR), decreased, Hodgkins disease, 230
399, 400 Hollow-point bullets, 253
Glomerulonephritis, 10 Hormonal therapy, or breast cancer, 193
Glucagonomas, 220 Horner syndrome, 230
Glucose urine strips, 271 Horseshoe abscesses
Goodsalls rule, 186, 187 intersphincteric plane, 187
Gra ing o deep burn, 299 ischiorectal plane, 187
Gravity cystogram, 313 management o , 186
Greater saphenous vein (GSV) stripping supralevator plane, 187
procedure, 345 Horseshoe stula, 187
Groin pain, a er hernia surgery, 73, 74 Houns eld units, 271
intentional ilioinguinal nerve division and, Hurthle cell neoplasms, 216
74, 7576 Hydralazine, and re exive tachycardia, 8, 9
management o , 73, 74 Hydrocephalus, 269
nerve injuries in hernia repair and, 73, 7475 Hydrocephalus ex vacuo, 271
primary nerve injury and, 73, 74 Hydroxocobalamin, 297, 298
secondary nerve injury and, 74 Hyperaldosteronism, 10
triple neurectomy or, 73, 75 Hyperbaric oxygen (HBO), 298
Guaiac ecal occult blood test (gFOB ), 184 treatment, 309, 310
Gunshot wounds, and ureteral injury, 405, 406 Hypercalcemia, 213
Gustatory sweating, 223 Hyperglycemia
and cerebral edema, 273
H severe, 302
Hand motion (HM), 286 signs o , 302
Head and neck malignancies, 230 Hypermethylation analysis, 185
Head and neck pediatric tumors, 227230 Hypernatremia, 279281
Head, Eye, Ear, Nose and T roat Exam de ned, 280
(HEEN ), 269 Hyperparathyroidism, 212214, 218
HELLP (Hemolysis, Elevated Liver enzymes, primary, 213
Low Platelets) syndrome, 134 retroesophageal space, 212, 213
Hemodialysis Hypokalemia, 210
complications o , 337339 Hypomagnesemia, 306
dyspnea/chest pain and, 337, 338 Hyponatremia, 269, 275, 279281
hypotension and, 337, 338 diagnosis o , 280
and muscle cramps in legs, 337338 neurological signs and symptoms o , 279
Hemodynamic instability, 262, 263 and transtentorial herniation, 279
Hemorrhagic brain contusions, 271 Hypotension, intradialytic, 337, 338
Hemostatic resuscitation, 247
Hemothorax, retained, 251 I
Heparin-induced thrombocytopenia (HI ), Idiopathic thrombocytopenic purpura (I P),
304, 306 150152
Hepatic unction tests, 184 accessory spleens in, 150, 152

pathophysiology o , 151
postoperative complications, 151, 152
splenectomy or, 150, 151
steroid-re ractory, 150, 151
thrombopoietin ( PO) receptor agonists in,
role o , 151, 152
Iliac vein, injury to, during trocar placement,
19, 20
Ilioinguinal nerve, injury to, 73, 75
Imatinib mesylate, 52
Imiquimod, or super cial basal cell carcinoma,
42
Immunohistochemical ecal occult blood test
(iFOB ), 184
In antile hypertrophic pyloric stenosis (IHPS),
232
acid-base dys unction, 232
diagnosis o , 232, 233
distal per oration o , 234
pathogenesis o , 232
In erior vena cava (IVC), 211
In ammatory breast cancer (IBC), 193,
199200
endocrine therapy or, 200
neoadjuvant chemotherapy or, 199, 200
pathophysiology o , 199
radiation therapy or, 199, 200
surgery in, 199, 200
tumor emboli in, 199, 200
In iximab, or intra-abdominal stulas, 176,
177
Inguinal hernia
asymptomatic, 67, 68
complications a er open repair o , 67, 68
direct, 68
elective surgery and watch ul waiting, 67, 68
indirect, 68
laparoscopic repair, 67, 69
nerve injury rom repair o , 67, 69
open repair o , 69
pantaloon-type hernia, 68
Inguinal neuralgia, 7376
Intercostobrachial nerve, injury, 192, 194
Intersphincteric abscesses, 187, 188
Intestinal atresia, 240
Intestinal malrotation, 236, 237
Intestinal obstruction, distal, 237
Intracerebral hemorrhage, 268
Intracranial hematomas, 265275
acute, 272
Intracranial hemorrhage, 267, 268
causes o , 268
and temporal hematomas, 268, 273
Intracranial pressure (ICP), 260, 279
dextrose and, 268, 273
monitor, 260
traumatic brain injury, 273
Intra-ductal papillary mucinous neoplasm
(IPMN), 147
Intraocular pressure (IOP), 286
Intraperitoneal (IP) chemotherapy, or ovarian
cancer, 356
Intra venous immuno globulin (IVIG), 321
Intravenous pyelogram (IVP), 313
Intraventricular catheter, 273
Intussusception
in adult, 160, 161
causes or, 161
in children, 161
surgery or, 161
Ipsilateral cancer, 192
Ipsilateral pupillary dilation, 272
Irishs node, 82, 85
Iron de ciency anemia, a er Roux-en-Y gastric
bypass (RYGB), 115116
Ischemic steal syndrome, 334, 335
J robotic-assisted (See Robotic-assisted
JD Robinson ormula, 5, 6
Jehovahs Witnesses (JW)
blood products acceptance and
consequences, 35, 36
blood trans usions and, 3536
dis ellowshipping, 35, 36
Junctional injuries, 246
Juvenile polyposis syndrome (JPS), 173
K Lichtenstein tension ree hernia repair with
Kernohans notch, 267, 271
Kidney stone
analgesia or renal colic, 395, 396
immediate decompression o renal unit,
395, 396
test or, 395
Kinetic energy equation, 253
Knee dislocations
and emergent closed reduction with
sedation, 386, 388
neurovascular injuries with, 387
popliteal artery, injury to, 387, 389
radiographs in diagnosis o , 386, 388
vascular injury with, 386387, 388389
Knee injuries, 386391
Kni e wounds, 249251
chest X-ray and FAS scan o , 250
C and C A o , 249, 251
hypotension in, 249, 250
le anterolateral thoracotomy, 249, 250
patients, ABCs o , 250
patients, management o , 249
tension pneumothorax, 250
KRAS mutation, 184
Krukenberg tumors, 85
L Lobular carcinoma in situ (LCIS), 191
Labetolol, 9
Laboratory risk indicator or necrotizing
asciitis (LRINEC) score, 308
Lactated ringers (LR), 297
Lamivudine, 325
Laparoscopic adjustable gastric band (LAGB)
placement, 120, 121
complication a er, 120, 121
gastric prolapse a er, 120, 121
gastropexy or gastric prolapse prevention,
121
outcomes rom, 120, 121
treatment or gastric prolapse,
121122
Laparoscopic cholecystectomy, 21, 22
In d e x 415
Laparoscopic gastric bypass, bowel obstruction
a er, 103105
and abdominal pain, 103, 104
C scan in, 103, 104
diagnostic laparoscopy in, 103104, 105
emergent exploration in, 103, 104105
and internal hernia, 103, 104, 105
intusseption at jejunojejunostomy in, 103, 104
Laparoscopic surgery
CO2 insuf ation in, 28, 2930
or colon cancer resection, 174
energy devices in, sa e use o , 28, 30
laparoscopic surgery)
robotic-assisted vs. traditional, 29
Lateral canthotomy, 282, 285
Lateral compression (LC III) racture, 262
Latissimus dorsi myocutaneous ap, 204, 205
Latissimus muscle, 200
Le Fort II/III injuries, 257
Levophed, 293
Levophed in usion, 291
mesh, 72
Li e-sustaining medical treatment, 37, 38
Li-Fraumeni syndrome, 192
Ligaments o Cooper, 194
Limb salvage surgery, or extremity sarcomas,
51
Lip carcinoma, 41, 4243
Liver cirrhosis, 140142
and ascites, 140, 141
gastrointestinal bleeding in, antibiotic
prophylaxis and, 141, 142
non-hepatic surgery in, 140, 141142
with spontaneous bacterial peritonitis, 141,
142
umbilical hernia and, 140, 141
Liver unction tests (LF ), 302
Liver, herniated, 239, 240
Liver metastasis, 137139
colorectal metastases, liver resection o , 137,
138139
concomitant colon and liver resections in,
137, 138
and neoadjuvant chemotherapy, 138, 139
surveillance in, 137, 139
Living wills, 38
Lobular carcinoma, 193
vs. DCIS, 198
Low anterior resection (LAR), 184
Lower motor neuron (LMN), 265
LRINEC scoring system, 309
Lumbar puncture, 272, 274
Lumpectomy, 191, 192, 193, 197
Lung cancer
and hyponatremia, 5657
non-small cell lung cancer (NSCLC), 55, 56
paraneoplastic syndromes with, 5657
PE scan in, 55, 56
relapse o NSCLC, 55, 56
right upper lobectomy, 55, 56
small cell lung cancer (SCLC), 5657
surgical resection, contraindication to, 55, 56
416 In d e x
Lymphangiomas. See Lymphatic mal ormation
Lymphangiosarcoma, 341, 342
Lymphangitis, 342
Lymphatic disease, 340342. See also
Lymphedema
Lymphatic mal ormation, 227, 229
Lymphedema, 197, 340, 341
diagnosis o , 340, 341
secondary, 340, 341
treatment or, 340, 341342
Lymphedema praecox, 341
Lymphedema tarda, 341
Lymphoma, 53
Helicobacter pylori in ection, and MAL
lymphoma, 51, 54
physical examination in, 50, 53
risk actors or, 5354
role o surgeon in, 53
staging or, 53
Lymphoscintigraphy, 340, 341
Lynch syndrome (LS), 172, 185, 354
M acute, 164
Ma enide acetate, or burn wound, 297, 299
Magnetic resonance angiography (MRA),
269
Magnetic resonance cholangiopancreatography
(MRCP), 147
or choledocholithiasis, 130, 131
Magnetic resonance imaging (MRI), 180
and nonnecrotizing in ections, 309
o pelvis, 183, 184
o sigmoid diverticulitis, 180
Magnetic resonance venography (MRV), 269
Malignant hypertension, 810
de nition o , 9
goal o care in, 8, 9
papillary edema in, 8, 9
renal artery stenosis and, 8, 910
sign o , 8, 9
Mallampati score, 6
Mammography, 192
limitations o , 197
Marcy repair, or hernia, 72
Marginal ulcers (MU), 100102
gastric bypass surgery and, 100, 101
per oration o , 101, 102
risk actors or, 100, 101, 105
smoking and, 100, 101
symptoms o , 101
treatment o , 101102
Mastectomy, 196
modi ed radical, 193
nipple-sparing, 202, 205
radical, 193
simple, 193
skin-sparing, 202
Mayo End-Stage Liver Disease (MELD) score,
65
May-T urner syndrome (M S), 343, 344
imaging modalities or, 344
management o , 344
pulmonary embolism and, 343, 344
Mcmurray test, 390
McVay repair, or groin hernias, 71, 72
Mean arterial pressure (MAP), 260, 273, 297
Mechanical colonic obstruction, 154
Mechanical small bowel obstruction, 154
Median arcuate ligament syndrome (MALS),
164
Medullary carcinoma, 211
Medullary thyroid cancer (M C), 218
Melanoma, 4749
acral lentiginous, 48
desmoplastic, 48
in-transit metastasis, 47, 49
lentigo maligna, 48
management o , 41, 42
metastatic sites or, 49
nodular, 48
prognostic indicators in, 47, 48
sentinel lymph node biopsy or, 47, 48
super cial spreading, 47, 48
wide local excision or, 47, 48
Merkel cell carcinoma (MCC), 41, 42
Merkel cell polyomavirus, 41, 42
Mesenteric ischemia, 163166
chronic, 164
diagnostic delays or, 163, 166
pathophysiologies or, 163, 164
risk actors with, 163, 164165
second-look laparotomy or, 163, 165166
surgical embolectomy or, 163, 165
venous, 164
Mesenteric venous thrombosis (MV ), 164
Mesh in ections, 63
Staphylococcus aureus and, 63
Metallic trocars, 30
Methemoglobin ormation, 274
Methotrexate, 360
Metoprolol, 9
MIBI scan, 213
Microsatellites (MSI), 185
Microscopic hematuria, 397
and upper urinary tract tumors, 397, 398
urinary diversion with ileum, and electrolyte
abnormalities, 397, 398
work-up or, 397398
Minimally invasive radioguided
parathyroidectomy (MIRP), 213
Minor consent authority, 35, 36
Mismatch repair protein analysis, 184
Model or End-Stage Liver Disease (MELD),
324
Modi ed radical mastectomy (MRM), 199,
200
Mohs microsurgery, or basal cell carcinoma,
41, 42
Molecular adenomatous polyposis (MAP), 173
Monoamine oxidase inhibitors (MAOI), 209
Monopolar instruments, use o , 28, 30
Monro-Kellie hypothesis, 260
Morel-Lavallee lesion, 262, 263
Motor de cit, 267
Motor vehicle collision
cardiac contusion, 290
patient, 288, 290
patient, VA S or, 288
Mucoepidermoid carcinoma, 221, 222
Mucosa-associated lymphoid tissue (MAL )
lymphoma, 51, 54
Helicobacter pylori in ection and, 51, 54, 91
Multicenter Selective Lymphadenectomy rial
II (MSL II), 48
Multi-organ dys unction syndrome (MODS),
292
acute kidney injury and, 292
Multiple endocrine neoplasia (MEN) 2A
syndrome, 216, 218
chromosome, gene and pathology o , 219
Multiple endocrine neoplasia (MEN) 2B
syndrome, 215, 216, 218
chromosome, gene and pathology o , 219
Multiple endocrine neoplasia (MEN)
syndrome, 211, 217, 218
chromosome, gene and pathology o , 219
Multiple gunshot wounds, 252254
arterial injury, 254
primary survey o , 253
resuscitative thoracotomy, 252, 253
stabilization o patients airway, 252, 253
urgent thoracotomy, 253
Mycophenolate mo etil, 322
Myxo brosarcoma, 52
N
National Comprehensive Cancer Network
(NCCN), 169
National Surgical Adjuvant Breast and Bowel
Project (NSABP), 193, 196
Natural ori ce translumenal endoscopic
surgery (NO ES), 22, 23
Necrolytic migratory erythema, 220
Necrotizing asciitis, 308310
occurrence o , 309
score, 309t
surgical debridement and, 308, 310
Necrotizing so tissue in ection, o perianal
area, 186, 187. See also Perirectal abscess
Negative pressure wound therapy (NPW ),
45, 298
contraindications to, 44, 45
devices or, 45
indications or, 45
macrode ormation o wound, 45
microde ormation o wound, 45
Neoadjuvant chemoradiation therapy, 184
Nephrolithiasis, 395396
Neuroblastoma, 230
Neurogenic diabetes insipidus, 280
Nissen undoplication, 95, 96
complications o , 29, 95, 96
Nitroprusside, 9
side e ects o , 8, 9
Non-depolarizing neuromuscular blockers, 67
Non-Hodgkins lymphoma, 230
Non-occlusive mesenteric ischemia (NOMI),
164
Nutcracker esophagus, 80, 81
O
Obesity hypoventilation syndrome (OHS), 6
criterion or, 5, 6
Obstructive sleep apnea (OSA), 57

Octreotide, 220
or carcinoid crisis, 161
Oculocardiac re ex, 286
Omega-3 atty acid, 302
Omeprazole, in gastroesophageal re ux disease,
95
Omphalocele, 239240
and gastroschisis, 240
and herniated liver, 240
management o newborn with, 239, 240
Operating room res, 1112
Ophthalmology trauma, 282286
anti-nausea medications or, 284
primary care o , 282, 283
tetanus shot or, 284
Orbital oor racture, 283
Orthotopic liver transplantation (OL ), 325
Osmotic demyelinating syndrome, 275
Osmotic medical therapy, 273
Ovarian cancer, 192
Ovarian masses, 353356
adjuvant chemotherapy or, 353, 356
BRCA1 mutations and, 353, 354
management strategy or, 353, 354355
surgical staging o , 353, 355356
trans-vaginal ultrasound ( VS) or, 353, 354
P Penetrating trauma, 252254
Paget-Schroetter syndrome, 348, 349
Pagets disease, 202
Pancreas mass
borderline resectable disease, 147, 148
C scan with arterial and venous phases in,
146, 147
in head o pancreas, 146148
neo-adjuvant therapy and resection, 146,
147148
pancreaticoduodenectomy or, 146, 147
Pancreatic endocrine tumors, 217220
Pancreatic stula, a er pancreatic surgery, 147,
148
Pancreatic neuroendocrine tumors (PNE ),
217, 218
clinical symptoms o , 218
ormal resection o , 217
Pancreaticobiliary maljunction (PBM), 124
Pancreaticoduodenectomy, 147, 148
Pancreatic pseudocysts, 144, 145
Pancreatitis
acute, 144, 145
causes o , 144, 145
diagnosis o , 144
morality rate, 144, 145
pseudocysts and, 145
trypsin in, 144, 145
Pancuronium, 7
Papillary carcinoma, 228
Parathyroid adenoma, 213
surgical excision o , 213
Parathyroid arteries, 214
Parathyroid gland hyperplasia, 213
Parathyroid hormone level (P H), 212
Parenteral nutrition (PN), 301, 302
catheter line in ection and, 301, 303
ormulations, 301, 302
gallbladder sludge and, 301, 302
zinc de ciency, 301, 302
Parkland ormula, 298
Parotidectomy
super cial, 221
total, 221
Parotid gland, 222
Pathologic complete response (pCR), 200
Patient controlled analgesia (PCA), 289
Pectoralis major muscle, 200
Pediatric trauma, 383385
and adults trauma patients, di erence
between, 383, 384
cervical spine evaluation and clearance, 383,
384
elbow injuries, 383, 384
pediatric diaphyseal emur racture, 383, 385
Pelvic racture, 262264
hemodynamic instability o , 262
hemorrhage, 263
mortality o displaced, 262
open, 262, 263264
diagnosis o , 264
management o , 262
patient, management o , 263
Pelvic hemorrhage, 245, 246
Pelvic in ammatory disease (PID), 362365
Pentalogy o Cantrell, 239, 240
Peptic ulcer disease per oration, 9899
esophagogastroduodenoscopy in, 98, 99
H. Pylori stool antigen testing in, 98, 99
laparoscopic Graham patch with H. Pylori
testing in, 98, 99
nasogastric tube insertion with NPO status
and IV uid initiation in, 9899
Percutaneous drainage, 180
Percutaneous transhepatic cholangiography
(P C), 131132
Percutaneous twist-drill bedside drainage, 270,
275
Periorbital ecchymosis, 286
Perirectal abscess, 186188
Perirectal suppuration, cause o , 187
Peritoneal dialysis, 337, 338
Peritonitis
management o , 337, 338339
peritoneal dialysis and, 337, 338
Permissive hypotension, 247
Per-oral endoscopic myotomy (POEM), or
achalasia, 21, 23
Petersens hernia, 104
Peutz-Jegher syndrome (PJS), 172
Pheochromocytoma, 10, 209, 210, 215, 399, 400
alpha-adrenergic blockade, 210
beta blockers, 210
normetanephrine levels, 210
plasma- ree metanephrine marker, 210
surgery or, 210
Phlegmon, 181
Picinabil, 229
Pitressin, 280
Pitressin,280
Pivot shi test, 390
Plagiocephaly, 230
In d e x 417
Plasmapheresis, 151
Platinum based therapy, or ovarian cancer,
356
Pleomorphic adenoma, 221, 222
Plug and patch repair, 72
Pneumocephalus, 271
compartments o , 271
de ned, 271
tension, 271
Pneumococci, 271
PO antibiotics, in sigmoid diverticulitis
treatment, 179
Polymerase chain reaction (PCR), 291
Positive end expiratory pressure (PEEP), 259,
292, 297
Positron emission tomography (PE ), 183, 216
in lung cancer, 55, 56
Post-mastectomy radiation therapy (PMR ),
200
Post-transplant lymphoproli erative disorder
(P LD), 322
Pregnancy
appendicitis in, 134136
cholecystitis in, 133136
gall bladder disease in, 134
imaging in, 134135
RUQ abdominal pain in, 134
Preperitoneal pelvic packing (PPP), 263
Preperitoneal repair, 72
Presacral drainage, or rectal injuries, 187.
See also Perirectal abscess
Pressure sores
caring or, 45
so tissue reconstruction, 44, 4546
staging o , 45
therapeutic treatment o , closure strategy in,
44, 46
unstageable, 44, 45
Primary care provider (PCP), 227, 232
Primary myelo brosis (PMF), 151
Prince v Massachusetts, 36
Propylthiouracil (P U), 10
Prostate cancer, 408409
and active surveillance, 408409
bladder neck contracture a er open
prostatectomy, 408, 409
obturator nerve, injury to, 408, 409
radical prostatectomy with bilateral pelvic
lymph node dissection, 408, 409
and rectal injury, 408, 409
Proton pump inhibitor (PPI), 219, 294
or gastroesophageal re ux disease, 94,
9596
or marginal ulcers, 101102
Pseudocysts, pancreatic, 144, 145
Pseudohyponatremia, 280
Psuedoachalasia, 81
Ptosis, unilateral, 274
Pulmonary metastatectomy, 399, 400
Punch biopsy, 199
Pyloric stenosis, 232234
Pyloric vein o Mayo, 234
Pyloromyotomy, 232
adequate, 233
intraoperative photograph o , 234
418 In d e x
Q Salpingectomy, 360361
17q chromosome, 191, 192
R antibiotics or, 265, 270
Ramstedt pyloromyotomy, 232, 233
Rectal adenocarcinoma, 184
Recto-sigmoid junction, 184
Rectum cancer, 183185
chemoradiation o , 183, 184185
Re exive tachycardia, 8, 9
Relative a erent pupillary de ect (RAPD), 283
Renal artery stenosis, and malignant
hypertension, 8, 910
Renal artery thrombosis, 322323
Renal cell carcinoma, 399, 400
Renal imaging, in blunt trauma patients, 313
Renal tumor, 399400
Renal ultrasound, 395
Renal vein thrombosis, 322
Restless leg syndrome, 302
Retrobulbar hemorrhage, 282, 284
Retrograde urethrography, 312, 313
Retroperitoneal lymph node dissection
(RPLND), complications o , 402, 403
Revisional bariatric surgery, 117119
Rhabdomyosarcoma, 230
Rigid proctoscopy, 183, 184
Rituximab, 151, 323
Roadside bomb, 245248
bleeding deaths, 246
hemorrhage and therapy, 245, 246
injury, initial care o , 245, 246
injury pattern o , 245
treatment
DCR in, 246, 247
DCS in, 245, 247
Robotic-assisted laparoscopic prostatectomy
(RALP), 25, 26
Robotic-assisted laparoscopic surgery,
2527
advantages o , 25, 26, 2829, 30
complications o , management o , 29
disadvantages o , 26
EndoWrist technology, 26
robotic-assisted vs. laparoscopic surgery or
colorectal cancer, 25, 26
and traditional laparoscopic surgery, 29
training program or, 26, 27
Rocuronium, 5, 67
Rombergs test, 269
Romiplostim, 152
Roux-en-Y gastric bypass (RYGB), 77, 78
abdominal pain a er, 103, 105
iron de ciency anemia a er, 115116
and marginal ulcers, 101 (See also Marginal
ulcers (MU))
Rule o nine, 298
S median time or leak healing, 108
SAGES FUSE course, 30
Salivary gland tumors, 221223
FNA o , 222
incisional biopsy o , 222
malignant, 223
signs and symptoms, 222
non-operative management, 154155
Sarcomas, 50, 5153 small bowel ileus and, 153, 154
Scalp wound, 265 surgical management, 154, 155
Small cell lung cancer (SCLC), 5657
management o , 265 Smoking, and marginal ulcers, 101
marked cosmetic de ormity, 270 Spinal cord injury, 256257
Scapula ractures, and pulmonary injury, 381 characteristics o , 257
Scapulothoracic dissociation, 380381 classi cation o , 257
chest X-ray in, 380, 381 in-line cervical alignment, 257
diagnosis o , 380, 381 NEXUS criteria, 256, 257
Sciatica, 371373 Spinal shock, 256
Scintigraphy, somatostatin-receptor, 219 treatment protocols or, 257
Sclerotherapy, in macrocystic lesions, 229 Splenectomy, 152
Secretin stimulation test, 99 Spontaneous bacterial peritonitis (SBP), 141, 142
Seidels sign, 283 Squamous cell carcinoma (SCC), o lip, 41,
Selective estrogen receptor modulator (SERM), 4243
197 Stereotactic core needle biopsy, 191, 192
Sentinel lymph node biopsy (SLNB), 193, 195, Sternocleidomastoid muscle (SCM), 228
196197 Stimulant drug abuse, 156158
or melanoma, 41, 42, 47, 48 Stool DNA testing, 173
or Merkel cell carcinoma, 42 Subarachnoid hemorrhage (SAH), 274
Sepsis and multi-organ ailure, 291295 causes o , 274
Sepsis therapy, 291, 292 complications o , 274
Sequential Organ Failure Assessment (SOFA) nuchal rigidity, 274
score, 294 Subdural hygroma (SDHG), 271
Seromas, a er ventral hernia repair, 63 Submandibular gland, 222
Serrated polyposis syndrome (SRS), 173 Super cial in erior epigastric artery (SIEA) ap,
Serum-ascites albumin gradient (SAAG), 141 204, 205
Serum CEA, 184 Superior mesenteric artery (SMA) occlusion,
Sestamibi scan, 212, 213 163, 164
Setons, 187 Superior mesenteric vein (SMV), 325
cutting, 187 Suppurative thyroiditis, 229. See also Head and
non-cutting, 187 neck pediatric tumors
Shoulder dislocations, 380, 381382 Supracondylar humerus ractures, 384385
anterior, 381 Supralevator abscesses, 186, 188
neurovascular injury with, 380, 382 Surgical nutrition, 301303
posterior, 381 Surgical site in ections, a er ventral hernia
radiographs in, 381382 repair, 61, 63
Shoulder trauma, 380382 Surrogates, 38
Sigmoidoscopy, in cancer diagnosis, 184 Surveillance, Epidemiology, and End Results
Silver nitrate, 299 (SEER), 193
Silver sul adiazine, 299 Syndrome o inappropriate antidiuretic
Single-incision laparoscopic (SIL) hormone (SIADH), 56, 275, 279, 280
cholecystectomy, 21, 2223 Systemic venous oxygen saturation (SvO2), 305
Single incision laparoscopic surgery, 174
Sister Mary Joseph node, 85 T
Sistrunk procedure, 228 acrolimus, 323
Skin cancer, 4143 ailored neurectomy, 75
and post-transplant immunosuppression, amoxi en ( MX), 192, 193, 195
323 adverse e ects o , 197
Skull racture, 271 in breast cancer treatment, 196, 197
compound depressed, 270 axanes, 200
open, 270 emporary access, cu ed, tunneled dialysis
Sleep apnea, 57 catheter or, 334, 335
Sleeve gastrectomy leaks, 106108 ension pneumocephalus, 266, 266 , 270
chronic stulae and leaks, management o , with Mount Fuji sign, 266 , 270
107, 108 eratomas, 230
endoluminal therapies or, 108 eriparatide shots, 213
esticular cancer, 402403
staple line leak rates, reducing o , 106, 107 bleomycin-induced pulmonary brosis, 402,
surgical treatment o , 106, 107108 403
sustained tachycardia and, 106, 107 metastasis to para-aortic lymph nodes, 402,
Small bowel obstruction, 153155 403
oley catheter and acute abdominal series, radical orchiectomy or, 402, 403
153, 154 scrotal ultrasound or, 402, 403
 In d e x 419

T iamine de ciency, a er bariatric surgery, 115 primary non- unction o , 325 V

T oracic gunshot wounds, 289 replantation, 326 Vacuum-assisted closure (VAC) techniques, or
T oracic injuries, 252, 254 ransureteroureterotstomy, 406 synthetic mesh in ections, 62, 63
T oracic outlet syndrome ( OS), 347349 ransverse rectus abdominis myocutaneous Varicose veins, 344, 345346
anatomic structure in thoracic outlet, 347, ( RAM) ap, 204, 205 Vascular access, 334336
348 rapdoor racture, 285 Vascular injuries, during trocar placement,
arterial, 348 rastuzumab, 193 1920
diagnosis/workup o , 347, 348349 rauma and critical care, 245248 diagnosis o , 19, 20
neurogenic, 348 rauma and subarachnoid hemorrhage, 268, and hemodynamic instability, 20
venous, 348 274 Vasopressor therapy, 293
T oracic trauma, 288290 rauma score, 305 Vecuronium, 7
T oracotomy, emergency, 250 raumatic brain injury, intracranial pressure Venous insu ciency, chronic, 341, 343345
T romboembolism, 218 monitoring in, 259 Venous stasis disease, 343346
T rombophlebitis, 342 rendelenberg test, 343, 344 Venous stasis ulcers, 344345
T rombopoietin ( PO) receptor agonists, 151, riangle o pain, 74 Ventral hernia
152 riple neurectomy, 73, 75 biologic mesh repair, 63
T rombotic thrombocytopenic purpura ( P), roisiers sign, 85 complications a er repair o , 61, 63
151 ube thoracostomy, 250, 252, 254 grading system or, 61, 62
T yroglossal duct cyst, 227, 228 ubo-ovarian abscess ( OA), 363365 inlay mesh repairs, 62
T yroid disease, 215216 antibiotic therapy or, 364 interpositinal repair, and recurrence, 61, 62
T yroid lobectomy, 214, 216 diagnosis o , 363 mesh in ections, 63
le , 215 surgical management, 364365 onlay mesh repair, 62
T yroid nodules, 216 teatment or, 363364 primary, 62
biopsy o , 216 umescent solution, 345 retrorectus repair, 62
risk actors, 216 umor gene sequencing, 185 secondary, 61, 62
T yroid storm, 10 umor, node, metastasis ( NM) model, 193 synthetic mesh in ections, vacuum-assisted
ibial plateau ractures, 387, 389 closure techniques or, 62, 63
knee injury with, 387, 389 U underlay type repair, 62
leg compartment syndrome with, 387, Ultrasound (US) Vertebral artery injuries, 257
390 abdominal aortic aneurysm, 331, 332 Vertical sheer (VS) racture, 262
management o , 389 biliary colic, 127, 128 Video-assisted thoracoscopic surgery (VA S),
idal volume ( V), 297 breast cancer, 192 250, 251, 288, 314
-lymphocytes, 322 IHPS diagnosis, 233, 233 or motor vehicle collision patient, 288
orticollis ovarian masses, 353, 354 Virchows node, 85
botulinum toxin in, 230 sigmoid diverticulitis, 180 Vitamin de ciency, a er bariatric surgery, 115
treatment or, 228, 230 testicular cancer, 402, 403 Vitamin K antagonists, 306
otal thyroidectomy, 209, 212, 215, 216 Umbilical hernia, cirrhosis and, 6465, 140, von Hippel-Lindau disease (VHL), 399, 400
ourniquets, 246 141 Von-Willebrand actor, 211
ranexamic acid ( XA), 246, 305 Uncal herniation, 271, 273
ransabdominal drainage, or cryptoglandular Un ractionated heparin (UFH), 304, 306 W
abscess, 187. See also Perirectal abscess Upper gastrointestinal contrast study (UGI), 232 Warthins tumor, 222
ranscranial doppler ( CD), 274 Upper tract urothelial carcinoma (U -UC), and Wernicke encephalopathy (WE), 115
ranscranial magnetic stimulation ( MS), 271 renal cell carcinoma, 399, 400 management o , 115
rans usion associated circulatory overload Ureteral injury, during colectomy, 405406 thiamine de ciency and, 115
( ACO), 305 Ureteral stone White-eyed blow out racture, 285
rans usion related acute lung injury ( RALI), hyperparathyroidism and, 395, 396 Withdrawing and withholding treatment, 37,
304, 305 passage o , estimation o , 395, 396 38
rans-jugular intra-hepatic shunt ( IPS) test or, 395 Wound healing, in chronic wounds, 45
procedures, 142 Ureteroneocystostomy, 405, 406 Wounds, di cult, management o . See Negative
rans mediastinal gunshot wounds, 289 Ureteroureterostomy, 405, 406 pressure wound therapy (NPW )
ransplant surgery Urethral injury, 315 Wuchereria banchro i, 340, 341
o kidney, 321323 Urethral stricture, in women, 314
hyperacute rejection, 322 Ursodiol, 22 Z
o liver, 324326 or gallstones, 128 Zollinger-Ellison syndrome, 219