ABSITE

Coagulation
• Vitamin K dependent coagulation factors?
• II, VII, IX, X, Proteins C and S
• Coagulation factor not synthesized in the liver?
• Factor VIII
• Where is it synthesized?
• Endothelium
• Mechanism of action of heparin/lovenox?
• Binds to ATIII enhancing activity.
• Most common inherited hypercoagulable state?
• Factor V Leiden, aka resistance to activated protein C
• Large, swollen, purple, painful leg. Diagnosis?
• Phlegmasia cerulea doleans
• Treatment?
• Emergent intervention either surgical thrombolysis or
thrombolytic catheter with tPA.
• HITT caused by what?
• Anti-platelet antibody to PF4
• Treatment if suspected?
• Stop all heparin products, diagnose with ELISA for
antibody +/- serotonin release assay, start direct thrombin
inhibitor argatroban or bivalirudin.
• Treatment for coagulopathy in uremic patient?
• DDAVP
Wound healing
• Dominant cells in wound healing days 0-2?
• Neutrophils
• Days 3-7?
• Macrophages
• Predominant collagen type present in wounds?
• Type I
• Difference between keloid and hypertrophic scar?
• Hypertrophic scars do not extend past the wound edges,
keloids do
Immunology
• Type I hypersensitivity reaction?
• Anyphylaxis, IgE, histamines, leukotrienes, bradykinin
• Type II?
• Antibody dependent cytotoxicity, IgM or IgG, ex. Acute
hemolytic transfusion reaction
• Type III?
• Immune complex deposition, serum sickness, lupus
• Type IV?
• Delayed type hypersensitivity reaction, T cell mediated
immune response, ex. Chronic rejection, graft vs. host
disease
Transplant
• Most important HLA used for donor/recipient matching?
• HLA DR
• What is panel reactive antibody?
• Crossmatch of recipient serum against panel of typing
cells.
• Hyperacute rejection mechanism and treatment?
• Preformed recipient antibodies against donor, ex. ABO
incompatibility, treatment is removal and immediate re-
transplant
• Acute rejection?
• Occurs 1week- 6 months after transplant, pre-sensitized T-
cells to donor, treatment is increased immunosuppression
ex. Pulse dose steroids
• Chronic rejection?
• Due to T-cells and antibodies, no good treatment
• Mechanism of action of cyclosporin?
• Binds cyclophilin protein and inhibits cytokine synthesis,
mainly IL-2.
• Tacrolimus?
• Binds FK binding protein also inhibiting cytokines, mainly
IL-2
• Main side effects to consider?
• Nephrotoxicity
• Most common malignancy following transplantation?
• Skin cancer
• Treatment of CMV infection?
• Ganciclovir
• DDx and management of low UOP/elevated cr s/p kidney
transplant?
• ATN of graft, vascular problem, urine leak or lymphocele
causing compression, rejection
• Check catheter
• Fluid challenge
• Lasix trial
• Duplex
• Nuc med study
• Biopsy
• Liver abscesses s/p liver transplant, cause?
• Hepatic artery thrombosis leading to biliary system
ischemia
• Most common cause of death after heart transplant?
• Chronic allograft vasculopathy, accelerated atherosclerosis
of small coronary arteries
Infection
• Types of necrotizing fasciitis?
• Type I – poly-microbial
• Type II – mono-microbial, usually Group A strep > > staph
• Type III – Gas gangrene due to clostridium perfringens
• Treatment of C. Diff in pregnancy?
• PO vanc
• Pattern of hepatitis serology with vaccination only?
• HbSab only
• Pattern with prior exposure?
• HbSab + HbCab (IgG) and/or HbEab, with no antigens
• Infection?
• See HbCab (IgM) and HbSag
• Mechanism of action of penicillins?
• Inhibition of cell wall synthesis
• Vancomycin?
• Same but not through penicillin binding protein
• Mechanism of action of tetracyclines/aminoglycosides?
• Inhibition of 30S subunit of ribosome
• Quinolones?
• DNA Gyrase inhibitors
• Bactrim?
• Inhibits dihydrofolate reductase
Anesthesia
• What does MAC mean?
• Minimum alveolar concentration of gas at which 50% of
the popluation will not react to an incision.
• Best indicator of successful tracheal intubation?
• End tidal CO2
• Causes of sudden decrease in end tidal CO2?
• Disconnect from circuit
• Cardiac arrest
• Pulmonary embolism
• CO2 embolism
• Cause of sudden increase in end-tidal CO2 with fever?
• Malignant hyperthermia
• Mechanism of action and treatment?
• Defect in calcium metabolism (ryanodine receptor defect)
causing flood of calcium release, treatment is to shut off all
anesthetics, give dantrolene and supportive care
• First muscle to go down and last to recover from
paralytics?
• Facial muscles
• Last to go down and first to recover?
• Diaphragm
• Only depolarizing neuromuscular blocker?
• Succinylcholine
• Non-depolarizing agent to use with hepatic and renal
dysfunction?
• Cisatracurium
• Why?
• Cleared by Hoffman elimination in plasma
• Max dosage of lidocaine with and without epi?
• With 7mg/kg, without 4-5mg/kg
• Bupivicaine?
• With 2-3mg/kg, without 2-3mg/kg
• Signs with toxicity?
• 1st is peri-oral parasthesias
• Hallucinations, sedation/unconsciousness, seizure,
respiratory and cardiac depression
• Treatment of bupivicaine overdose?
• Intralipid or propofol
• Largest risk factor for peri-operative cardiac event?
• Decompensated heart failure
• How long do you need to wait after MI for elective surgery?
• Minimum 6-8 weeks
Electrolytes
• Composition of LR?
• Na – 130
•K–4
• Cl – 109
• Ca – 2.7
• Lactate - 28
• Calculate free water deficit?
• 0.6 x weight in Kg x (Na/140 – 1)
• First line treatment of hyponatremia?
• Free-H2O restriction
• EKG findings of hyperkalemia?
• Tall tented T’s
• V. fib
• Most important treatment in symptomatic hyperkalemia?
• Calcium gluconate
• EKG findings of hypokalemia?
• Absent or inverted T-waves, U-waves
• Treatment of acute hypercalcemia?
• Aggressive hydration with IVF
• Once UOP adequate add lasix
• dialysis
• Acid/Base disorders!!!!!
• pH tells you if acidosis or alkalosis
• CO2 tells you if respiratory or metabolic primary
• Normal values?
• pH 7.35-7.45
• pCO2 35-45
• HCO3 25-30
• 7.2 50 25
• Respiratory acidosis
• 7.2 30 15
• Metabolic acidosis
• 7.5 50 37
• Metabolic alkalosis
• 7.5 20 25
• Respiratory alkalosis
Nutrition
• Calories generated from?
• Fat
• Protein
• Carbs
• Fat – 9kcal/g
• Protein – 4kcal/g
• Carbs – 3.4-4 kcal/g (IV vs. PO)
• Basal energy needs? Protein needs?
• 25 kcal/kg/day
• 1-1.5 g/kg/day
• Essential fatty acids?
• Linoleic and linolenic
• Most common amino acid?
• Glutamine
• Major fuel source for?
• Small bowel
• Large bowel
• Liver
• Heart
• Brain
• Cancer cells
• Small bowel - glutamine
• Large bowel – short chain fatty acids
• Liver – ketones
• Heart – short chain fatty acids
• Brain – glucose
• Cancer cells – glutamine
• What does respiratory quotient mean?
• CO2 produced to O2 consumed
• What is RQ for?
• Fat
• Protein
• Carbs
• overfeeding
• Fat – 0.7
• Protein – 0.8
• Carbs – 1.0
• Overfeeding - >1
• Normal half-lives for?
• Albumin
• Prealbumin
• Albumin – 20 days
• Prealbumin – 2-3 days
• Signs and symptoms of deficiencies?
• Thiamine (B1)
• Pyridoxine (B6)
• Cobalamine (B12)
• Folate
• Thiamine – Wernicke’s encephalopathy, peripheral
neuropathy
• Pyridoxine – peripheral neuropathy
• Cobalamine – megaloblastic anemia, peripheral
neuropathy
• Folate – megaloblastic anemia without peripheral
neuropathy
Oncology
• Proto-oncogenes?
• Growth factors, tyrosine kinases, G-protein receptors,
transcription factors.
• PDGF, VEGFR, PDGFR
• HER/neu
• ras family
• myc family
• Tumor suppressor genes?
• APC
• P53
• BRCA 1 and 2
• Cell phase most vulnerable to radiation therapy?
• M phase
• Tumor markers
• CEA
• AFP
• CA 19-9
• CA 125
• Beta HcG
• CEA - colon
• AFP - HCC
• CA 19-9 – pancreatic adenoca
• CA 125 - ovarian
• Beta HcG – testicular ca
Trauma
• Borders of the cardiac “box”?
• Nipples, thoracic inlet, costal margin
• If stable and wound in box need to rule out what?
• Tamponade
• How to diagnose?
• FAST with pericardial views
• Pericardial window especially if there is a pleural effusion
• Amounts out of chest tube that “mandate” exploration?
• >1000-1500 immediately
• >250 cc/hr for >3 hours
• GCS?
• Eye
• Verbal
• Motor
• Eye
• 4 spontaneous
• 3 to voice
• 2 to pain
• 1 does not open
• Verbal
• 5 oriented
• 4 confused
• 3 inappropriate words
• 2 sounds
• 1 nothing
• Motor
• 6 follows commands
• 5 localizes
• 4 withdraws
• 3 decorticate (flexion)
• 2 decerebrate (extension)
• 1 nothing
• Best prognostic factor of GCS?
• Motor
• Indications for ICP monitor?
• GCS < 8
• Cerebral perfusion pressure equation and goal?
• CPP = MAP – ICP
• Goal CPP > 60-70
• Zones of neck?
• Zone 1 – Clavicles to cricoid
• Zone 2 – cricoid to angle of mandible
• Zone 3 –angle of mandible to skull base
• Symptoms mandating neck exploration?
• Shock
• Hard signs of arterial injury ie. Pulsatile bleeding, rapidly
expanding hematoma, ipsilateral stroke
• Lack of airway control, massive subcutaneous
emphysema
• Workup for neck injuries?
• 4 vessel angio or CTA
• Endoscopy +/- barium esophagram
• Bronchoscopy
• Area of concern for diaphragmatic injury?
• Nipples to costal margin
• How to approach diaphragm injury?
• Trans-abdominal if early (<1 week)
• Trans-thoracic if delayed
• Signs of aortic injury on CXR?
• Widened mediastinum
• Apical capping
• Loss of aortic knob contour
• Loss of AP window
• Tracheal deviation to right
• Left mainstem deviated inferiorly
• Most common site of aortic transection?
• Ligamentum arteriosum just distal to left subclavian
• If hemorrhagic shock with splenic laceration and aortic
transection which is treated first?
• Spleen
• Best incision for?
• Right innominate
• Left common carotid
• Left subclavian
• Right innominate – median sternotomy
• Left common carotid – median sternotomy with extension
to left neck
• Left subclavian – High left anterolateral thoracotomy (2-3
interspace), trap door
• Treatment of rectal injury?
• Intra-peritoneal
• Extra-peritoneal
• Intra-peritoneal – resect/repair same as colon injury
• Extra-peritoneal – divert, pre-sacral drainage only if pelvic
sepsis
• Blunt abdominal trauma indications for laparotomy?
• Shock
• Peritonitis
• Indications for angiography in liver/spleen/pelvis trauma?
• Evidence of active contrast extravasation
• ? Grade 4 and 5 injuries
• Indications for operation in pancreatic trauma?
• Ductal transection
• Zones of retroperitoneal hemmorhage?
• Zone 1 – Central (between renal hila)
• Zone 2 – lateral (lateral to renal hila)
• Zone 3 – pelvic
• Which mandate exploration?
• All zone 1
• Zone 2 with hard signs of vascular injury and most
penetrating
• Zone 3 with hard signs of vascular injury and penetrating
• Hard signs of vascular injury?
• Pulsatile bleeding
• Frank ischemia distally
• Expanding or pulsatile hematoma
• Bruit or thrill
• Management if hard sign of vascular injury?
• OR
• Soft signs?
• Hemorrhage or hematoma that is non-pulsatile
• Defecit of anatomically related nerve
• Proximity to major artery
• Unequal pulses
• ABI < 0.9
• Commonly associated injuries?
• Anterior shoulder dislocation
• Posterior shoulder dislocation
• Midshaft humeral fracture
• Supracondylar humeral fracture
• Anterior hip dislocation
• Posterior hip dislocation
• Knee dislocation
• Fibular head fracture
• Anterior shoulder dislocation – Axillary nerve
• Posterior shoulder dislocation – axillary artery
• Midshaft humeral fracture – radial nerve
• Supracondylar humeral fracture – brachial artery
• Anterior hip dislocation – femoral artery
• Posterior hip dislocation – sciatic nerve
• Knee dislocation – popliteal artery
• Fibular head fracture – common peroneal nerve
• Management of ureteral injuries?
• Upper 1/3rd
• Middle 1/3rd
• Lower 1/3rd
• Upper 1/3rd – primary repair over stent or end-end repair
over stent
• Middle 1/3rd – same
• Lower 1/3rd – reimplant +/- psoas hitch
• Classes of shock?
• Class I – 0-15% of volume 0-750cc
• Class II – 15-30% of volume 750-1500 cc, see narrowed
pulse pressure, tachycardia
• Class III – 30-40% of volume 1500-2000cc, see
hypotension, altered mental status
• Class IV - >40% of volume, >2000cc, obtunded
Critical Care
• Most important component in oxygen delivery?
• Hemoglobin
• Shock states!!!!
• ↓ CO
• ↑ SVR
• ↑ CVP/wedge
• Cardiogenic or obstructive (PE, tamponade)
• ↓ CO
• ↑ SVR
• ↓ CVP/wedge
• Hemorrhagic
• ↑ CO
• ↓ SVR
• ↓ CVP/wedge
• Sepsis (early)
• ↓ CO
• ↓ SVR
• ↓ CVP/wedge
• Neurogenic or anyphylactic
• MOA of phenylephrine?
• Pure alpha I
• Epinephrine?
• Low dose predominantly beta 1 and 2, high dose
predominantly alpha 1 and 2
• Norepinephrine?
• Predominantly alpha 1 and 2 but with some beta
• Dopamine?
• Low dose dopa receptors, moderate dose beta 1 and 2,
high dose alpha 1 and 2
• Vasopressin?
• V1 receptor
• Milrinone?
• Phosphodiesterase inhibitor through cAMP, increased Ca
influx and afterload reduction (inodilator)
• IABP works how?
• Inflates during diastole to improve perfusion to coronaries,
deflates during systole to decrease afterload
• RAAS system?
• Kidney -> renin due to decreased pressure at juxta-
glomerular apparatus and increased sodium at macula
densa
• Renin cleaves angiotensinogen -> angiotensin I
• ACE in lung converts to angiotensin II
• Angiotensin II causes
• Vasoconstriction
• Release of ADH
• Release of aldosterone
• Indications for hemodialysis?
• A - acidosis
• E – electrolyte abnormalities, ie. hyperkalemia
• I – ingestion of toxins, ie. Methylene glycol
• O – overload (fluid)
• U – uremia (encephalopathy, coagulopathy, pericarditis)
• Pulmonary function testing
• Tidal volume?
• Volume of air with normal inspiration and expiration
• FVC?
• Volume of air able to be expelled after maximal inhalation
• Residual volume?
• Volume left after FVC
• Functional residual capacity?
• Volume left after normal exhalation
• Minute ventilation?
• RR x TV
• How to increase oxygenation with ventilator settings?
• Increase FiO2 and increase PEEP (which increases FRC)
• How to diagnose ARDS?
• Acute onset (<1 week from insult)
• Bilateral infiltrates
• Rule out CHF
• PO2/FiO2 ratio of
• 200 - 300 = mild ARDS
• 100 - 200 = moderate ARDS
• <100 = severe ARDS
• Treatment for ARDS?
• Low tidal volume ventilation 6ml/kg
• Definition of abdominal compartment syndrome?
• Abdominal hypertension ( >20mm/hg) associated with
organ failure
Burns
• Difference between 1st, 2nd, and 3rd degree burns?
• 1st – epidermis only, sunburn
• Superficial 2nd –painful, blistering, will heal
• Deep 2nd – painful but with decreased sensation, usually
require skin grafts
• 3rd – insensate, leathery
• 4th – down to bone/muscle
• Parkland formula?
• 4cc/kg/%BSA burned with 2nd/3rd degree
• ½ in first 8 hours, ½ in next 16.
• Starts from time burned
• Generally only use if >20% BSA burned
• Treatment for deep 2nd and 3rd degree burns?
• Early excision and grafting
• Criteria for diagnosis of burn wound infection?
• Biopsy with > 105 organisms
• Side effects of silvadene?
• Neutropenia and thrombocytopenia, limited eschar
penetration
• Silver nitrate?
• Methemoglobinemia, electrolyte abnormalities, skin
discoloration
• Mafenide (sulfamylon)?
• Metabolic acidosis, painful to administer

• Good eschar penetration and good for cartilage

Head and Neck
• Treatment of thyroglossal duct cyst?
• Antibiotics if infected, then Sistrunk procedure with
resection of the cyst, midportion of hyoid bone and tract
from foramen cecum
• Most common site of iatrogenic esophageal perforation?
• At the level of the cricopharyngeus
Adrenal
• Adrenal cortex anatomy?
• G (glomerulosa) – salt, aldosterone
• F (fasciculata) – sugar, corticosteroids
• R (reticularis)– sex, androgens
• Medulla - Catecholamines
• Enzyme that converts norepinephrine to epinephrine?
• PNMT (phenylethanolamine – N – methyltransferase)

• Only in adrenal hence only adrenal pheos produce

epinephrine
• Most common cause of congenital adrenal hyperplasia?
• 21-hydroxylase deficiency
• Workup of adrenal incidentaloma?
• Pheochromocytoma – 24 hour urine metanephrines or serum
metanephrines
• Cushing’s syndrome – low dose dexamethasone suppression
test, 24 urine cortisol/ACTH
• Aldosteronoma – Serum renin, aldosterone, K+
• Adrenocortical carcinoma - DHEAS
• FNA only once these have been ruled out to diagnose
metastatic lesion
• Indications for operation with adrenal incidentaloma?
• Functional tumor
• Size > 4-6cm
• Suspicious features suggesting malignancy (complex,
hemorrhagic, heterogenous, vascular appearance)
• FNA suggesting oligometastatic disease
• Most common location of pheo?
• Adrenal
• Most common extra-adrenal location of pheo?
• Organ of Zuckerkandl just above aortic bifurcation
• Test if concern for pheo but no adrenal mass on CT?
• MIBG scan (131-meta-iodobenzylguanadine)
• Pre-operative management of pheo?
• Alpha blockade with phenoxybenzamine or prazosin until
orthostatic hypotension then beta blockade if tachycardic
Endocrine
• Blood supply of parathyroid glands?
• Inferior thyroid artery
• Origin of parathyroids?
• Superior from 4th pharyngeal pouch, inferior from 3rd
pharyngeal pouch
• Only laryngeal muscle not supplied by recurrent laryngeal
nerve?
• Cricothyroid
• Supplied by?
• External branch of superior laryngeal nerve off vagus
• Workup of thyroid nodule?
• Thyroid function tests and FNA
• If FNA suggests papillary CA, treatment?
• Total thyroidectomy
• If FNA shows follicular neoplasm?
• Thyroid lobectomy
• Hurthle cell neoplasm?
• Lobectomy
• After thyroidectomy what do you follow to evaluate for
recurrence?
• Thyroglobulin
• Amyloid seen on FNA?
• Medullary thyroid CA
• Cells of origin of medullary thyroid CA?
• Parafollicular C-cells
• Indications for thyroidectomy in Grave’s disease?
• Suspicious nodule or cancer
• Failed medical therapy
• Pregnancy with failure of medical therapy (no I-131)
• Side effects of PTU?
• Aplastic anemia and agranulocytosis
• Side effects of methimazole?
• Same but also cannot use in pregnancy
• Mechanism of action of PTH?
• Increased Ca reabsorption in kidney along with
phosphorus excretion
• Increased hydroxylation of vitamin D in kidney (1-alpha
hydroxylation)
• Increased osteoclast resorption of bone
• How do you differentiate primary hyperparathyroidism from
FHH?
• FHH has low urine calcium and low to low-normal PTH
• Primary hyperparathyroidism has high urine calcium and
high to high-normal PTH
• Symptoms of hypercalcemia?
• Stones – kidney stones
• Bones – bone pain, osteoporosis
• Groans – abdominal pain
• psychic overtones – depression
• Indications for minimally invasive parathyroidectomy?
• Preoperative localization study, either ultrasound or
sestamibi scan
• Appropriate decrease in intra-operative PTH
• What is appropriate drop?
• >50% in 10 minutes from removal
• Treatment for 4 gland hyperplasia?
• Either 3 and ½ gland resection or 4 gland resection with
reimplantation in forearm or SCM (generally forearm for
MEN associated disease)
• Locations of missing glands if you can only find 3?
• Thymus, within carotid sheath, tracheo-esophageal
groove, intra-thyroidal
• What to do if you find 3 normal glands only despite looking
in all the aforementioned places?
• Ipsilateral thyroid lobectomy, close and image post-
operatively if still hypercalcemic, no sternotomy at that
time
• Gene and diseases with MEN I?
• MENIN, three Ps, parathyroid hyperplasia, pancreatic
neuroendocrine tumors (most commonly gastrinoma), and
pituitary adenomas
• MEN Iia?
• RET proto-oncogene, Medullary thyroid CA,
pheochromocytoma, and parathyroid hyperplasia
• MEN IIb?
• RET proto-oncogene, medullary thyroid CA,
pheochromocytoma, marafinoid habitus, mucosal
ganglioneuromas
• Most common cause of death in those with MEN IIa-b?
• Medullary thyroid CA
• Age at which prophylactic thyroidectomy is indicated?
• IIa - < 5 years
• IIb – < 1 years
Breast
• Injury results in winged scapula?
• Long thoracic nerve
• Injury to thoracodorsal nerve results in?
• Weak arm adduction (pull ups, latissimus dorsi)
• Most common nerve injured in axillary dissection?
• Intercostobrachial nerve
• Breast feeding mom with painful, red area on breast,
treatment?
• I&D, continue breast feeding
• 25 yo F with firm, rubbery mass, distinct borders,
hypoechoic on US, next step, definitive treatment?
• Biopsy, excision unless <30, feels clinically benign, looks
clinically benign on US, and biopsy consistent with
fibroadenoma.
• Painful cordlike swelling on breast, diagnosis and
treatment?
• Mondor’s disease, NSAIDS
• Most common cause of unilateral nipple discharge?
• Intraductal papilloma
• Workup and Treatment?
• Mammogram, Ductography, excision
• BiRADS classification and what you need to do about it?
• 0 – incomplete, further investigation
• 1 – negative, routine screening
• 2 – benign findings, routine screening
• 3 – probably benign findings, short interval follow up
• 4 – suspicious findings, biopsy
• 5 – highly suspicious findings, biopsy
• 6 – biopsy proven malignancy
• Suspicious microcalcifications on mammography, biopsy
shows LCIS, next step?
• Excisional biopsy (seed loc, needle loc) of microcalcs, due
to discordance
• Risks associated with LCIS? Treatment options?
• Risk of ductal adenocarcinoma in both breasts, not lobular
carcinoma. As above need to resect if abnormality seen
on imaging with LCIS on biopsy, do not need negative
margins
• Treatment options include careful follow up, hormonal
therapy, bilateral simple mastectomy
• Microcalcifications seen on mammography, biopsy with
DCIS, treatment?
• Lumpectomy with radiation, no sentinel node
• Multi centric DCIS?
• Simple mastectomy with sentinel node biopsy as there is
chance of upstaging and once you do mastectomy you
cannot go back and do sentinel node
• Which BRCA has greater risk of ovarian CA?
• BRCA 1
• Male breast CA?
• BRCA 2
• Cystic lesion in breast, treatment algorithm?
• Mammography and US, Aspiration and cytology. If simple
with negative cytology and disappears you are done. If
bloody, complex, recurs after aspiration need excision.
• Adjunct therapy if HER2/neu positive?
• Trastuzumab (Herceptin)
• Side effects?
• Cardiotoxicity
• Patient with breast cancer and palpable lymphadenopathy
in axilla, treatment?
• Axillary dissection
• Lymph node levels in axillary dissection?
• I – lateral to pec minor
• II – beneath pec minor
• III – medial to pec minor (not necessary for ALND)

• Rotter’s nodes – between pec major and minor

• Large well circumscribed mass, biopsy comes back
phyllodes tumor, treatment?
• Wide local excision with 1cm margins, no
lymphadenectomy.
• Firm mass in breast with redness of skin, how to
diagnose?
• Full thickness punch biopsy of skin.
• What will you find?
• Tumor cells infiltrating dermal lymphatics.
• Treatment?
• Neoadjuvant chemoradiotherapy followed by mastectomy
and ALND
• Crusted lesion on nipple, diagnosis and next step?
• Paget’s disease from underlying DCIS of ductal CA, need
biopsy, workup for breast cancer with breast exam,
bilateral mammography
• Pregnancy and breast CA, what is contraindicated?
• XRT, lymphazurin or methylene blue, chemo in first
trimester
• Technetium labelled sulfur colloid is safe
Thoracic
• Difference between type I and II pneumocytes?
• Type I responsible for gas exchange
• Type II make surfactant
• PFTs needed before pulmonary resection?
• Need predicted post-op FEV1/DLCO of >40%
• Need pre-op PCO2 <45, PO2 >60 not on O2, VO2max
>10ml/kg/min
• What if you are borderline, next step?
• V/Q scan
• Nodal staging of lung cancer, what makes you
unresectable?
• N2 disease, ipsilateral hilar or carinal nodes
• N3 disease, contralateral mediastinal or hilar nodes,
supraclavicular nodes
• Treatment for thymoma?
• Resection
• Course of the thoracic duct?
• Enters through aortic hiatus in right chest, crosses to left at
T5-6, enters at the confluence of left subclavian and
internal jugular veins
• Treatment of chylothorax?
• Initially conservative with chest tube, tpn, short/medium
chain fatty acids
• If fails attempt thoracic duct ligation at entry into thorax on
right
• Congenital cyanotic heart diseases?
• Transposition of great vessels
• Tetrology of fallot
• Truncus arteriosus
• Tricuspid atresia
• Total anomalous pulmonary venous return
• What is the tetrology of tetrology?
• VSD
• Pulmonary stenosis
• RVH
• Overriding aorta
• How do you keep a PDA open, how do you close it?
• Prostaglanding keeps it open
• Indomethacin closes it
• Classifications of aortic dissection?
• Stanford A – any involvement of ascending aorta
• Stanford B – No involvement of ascending aorta

• Debakey I – both ascending and descending

• Debakey II – ascending only
• Debakey III – descending only
• Indications for operating in acute type B (Debakey III)
dissection?
• Rupture, aneurysmal expansion, organ or limb ischemia,
uncontrolled HTN or intractable pain.
Vascular
• Patient with stroke with occluded ipsilateral carotid,
treatment?
• Nothing
• Patient with blunt trauma to neck, stroke, and ipsilateral
carotid thrombosis, treatment?
• What will you see with hypoglossal nerve injury during
CEA?
• Tongue deviation to the side of injury
• Patient is s/p CEA, now with hemiparesis in PACU, next
step?
• Immediate return to OR for exploration, get CT post-op
• Operative repair
• Patient with claudication, imaging shows SFA lesion,
treatment?
• Medical therapy with statins, smoking cessation, exercise
program, asa etc.
• Intervention for life limiting claudication despite maximal
medical therapy
• Indications for intervention for AAA?
• > 5.5 cm in men, > 5cm in women, growth >0.5cm/year,
symptomatic
• Patient with remote history of AAA repair, now with GI
bleed, fever. Diagnosis and treatment?
• Aortoenteric fistula to duodenum with graft infection.
Treatment includes graft resection, closure of fistula, aortic
stump closure.
• Reconstruction options include, extra-anatomic, in-line with
vein, cryovein, or rifampin soaked dacron.
• Patient s/p EVAR now with bloody BMs, next step?
• Flex sig to look for ischemic colitis
• Indications for intervening on splenic artery aneurysm?
• Pregnant
• Child bearing age
• Symptomatic
• >3-4cm
GI Hormones
• Secreted by?
• Stimulated by?
• Inhibited by?
• Response?
• Gastrin?
• Secreted by G cells in antrum and duodenum
• Stimulated by vagal input, high pH in stomach, antral
distension, protein content
• Inhibited by low pH in stomach, CCK, somatostatin,
secretin
• Causes increased HCl, pepsinogen, intrinsic factor
secretion
• Somatostatin?
• Secreted by D cells in antrum
• Stimulated by acid in duodenum
• The great inhibitor, inhibits basically everything
• CCK?
• Secreted by I cells of the duodenum and jejunum
• Stimulated by protein and fat in the duodenum
• Causes gall bladder contraction and relaxation of sphincter
of oddi, increased pancreatic enzymatic secretion,
increased intestinal motility
• Secretin?
• S cells of the duodenum
• Stimulated by acid, fat, bile in duodenum
• Inhibits gastrin and HCl release, stimulates pancreatic
HCO3 secretion from ductal cells
• Glucagon?
• Alpha cells in pancreatic islets
• Stimulated by decreased serum glucose, increased amino
acids, vagal stimulation, catecholamines
• Inhibited by increased serum glucose, inuslin
• Causes glycogenolysis and gluconeogenesis, lipolysis and
ketogenesis, proteolysis
• Insulin?
• Secreted by beta cells in pancreatic islets
• Stimulated by serum glucose, CCK
• Inhibited by somatostatin
• Causes cellular glucose uptake, protein, glycogen, and fat
synthesis
• Function of parietal cells?
• Secrete HCl and intrinsic factor
• Chief cells?
• Pepsinogen
• Where are the highest concentration of motillin receptors
and what drug affects them?
• Gastric antrum and erythromycin
• Bowel recovery after surgery?
• Small bowel recovers in 24 hours
• Stomach in 48 hours
• Large bowel in 3-5 days
Esophagus
• Layers of the esophagus?
• Mucosa
• Submucosa
• Muscularis propria (Upper esophagus is striated muscle,
lower is smooth)
• Inner circular
• Outer longitudinal
• Surgical approach to cervical esophagus?
• Left neck
• Upper 2/3rds of the thoracic esophagus?
• Right chest (avoids aorta)
• Lower 1/3rd?
• Left chest
• Patient with dysphagia, initially solids only but now liquids
too, constantly regurgitating undigested foods, initial
workup?
• Barium esophagram, EGD, manometry.
• Two key manometric features of achalasia?
• Failure of LES to relax, aperistalsis
• Rule out pseudoachalasia with EGD
• Mechanism of achalasia?
• Loss of ganglion cells in Auerbach’s myenteric plexus
• Treatment options?
• Botox, balloon dilation, heller myotomy (carry onto
stomach), POEM (probably not on ABISTE yet)
• When doing a heller, you notice full thickness perforation,
what do you do?
• Cover with stomach wrap (Dor or Toupet) perform
myotomy at another site
• Treatment for end stage achalasia with burned out, non-
functional esophagus?
• Esophagectomy
• High amplitude, non-peristaltic, repetitive contractions?
• Diffuse esophageal spasm
• Treatment?
• Medical first line, calcium channel blockers, surgical
treatment is long myotomy
• Nutcracker vs. DES?
• Nutcracker has high amplitude >180 mm/hg
• 80 yo M with dysphagia and regurgitation of undigested
food, diagnosis?
• Zenker’s.
• What is the cause/treatment?
• Ineffective relaxation of cricopharyngeus, treatment is
cricopharyngeal myotomy +/- resection/suspension of
diverticulum, but myotomy is the key.
• 40 yo alcoholic shows up with altered mental status,
vomiting, septic, left pleural effusion on CXR, likely
diagnosis and workup?
• Boerhaave’s. Triple (water soluble, thin barium, regular
barium) contrast study +/- CT chest.
• Treatment?
• Left thoracotomy, primary repair, may need to extend the
perf to better visualize the mucosal injury, repair in 2
layers, intercostal muscle flap
• Patient with achalasia s/p balloon dilation now with severe
chest pain, work up and probable treatment?
• Same. Incision based upon location of perforation.
• 4 yo child with dysphagia, may have swallowed something.
Where is it stuck and what is management?
• At the level of cricopharyngeus, go get it with rigid
esophagoscopy. Cannot leave things in the esophagus. If
it is in the stomach can consider leaving it and observing.
• What is barrett’s esophagus?
• Intestinal metaplasia
• Surveillance?
• Annual EGD with 4 quadrant biopsies every 1cm (Seattle
protocol)
• Biopsy shows high grade dysplasia, management?
• Endomucosal resection or ablation.
• Biopsy shows adenocarcinoma, next steps?
• Staging, CT Chest, Abdomen, Pelvis, EGD with EUS, PET
scan.
• T stages?
• T1a vs. T1b – T1b is indication for esophagectomy
• T2 vs. T3-4 - >T2 is indication for neoadjuvant
chemoradiotherapy.

• If tumor penetrates muscuaris mucosa, need

esophagectomy, if penetrates muscularis propria,
generally do neoadjuvant chemoradiotherapy.
• Blood supply for gastric conduit?
• Right gastroepiploic artery
• Hiatal hernia types?
• I – sliding
• II – true paraesophageal
• III – mixed
• IV – other intra-abdominal organs
• Management?
• Repair all type II, III, IV in good operative candidates, if
very poor surgical candidate and emergency can perform
gastropexy.
• Type I repair if other indication for Nissen i.e. GERD.
• Patient with dysphagia, EGD shows smooth submucosal
mass with intact mucosa, diagnosis and management?
• Leiomyoma, do not biopsy, enucleate
Stomach
• Bleeding duodenal ulcer, EGD sees bleeding vessel, they
control it, 48 hours later bleeding again, next step?
• EGD again. If that fails, OR vs. IR.
• Gastric ulcer types?
• I – Lesser curve
• II – pre and post pyloric
• III – pre-pyloric
• IV – Cardia
• V – diffuse, due to NSAIDS

• II and III are due to high acid secretion so require acid

reducing operation or PPIs
• Indications for operating on ulcers?
• Perforation
• Obstruction
• Bleeding despite multiple attempts at EGD control,
bleeding with shock despite resuscitation, bleeding with
>4-6 units of blood
• Inability to rule out cancer, i.e. failure to heal (usually >3
months)
• Patient with prior bilroth II reconstruction now with post-
prandial abdominal pain which improves with large volume
bilious emesis, diagnosis and treatment?
• Afferent loop syndrome from obstruction of the
biliopancreatic limb. Treatment is revision of the
gastrojejunostomy usually to roux-en-Y.
• Which ulcers need to be biopsied?
• All gastric ulcers, generally not duodenal ulcers.
• Best test for H. pylori?
• Biopsy with histologic examination
• Best test to follow for eradication of H. Pylori?
• Breath test
• Treatment options for H. Pylroi?
• PPI
• Clarithromycin or Amoxicillin
• Metronidazole
• +/- carafate
• Describe the operation for bleeding duodenal ulcer.
• Patient with perforated duodenal ulcer, so large that it
cannot be closed or patched. Management?
• Pyloric exclusion. Staple across with TA or sew closed
pylorus, gastrojejunostomy, with feeding jejunostomy and
either retrograde or lateral duodenostomytube, widely
drain area.
• Alcoholic patient with massive UGIB, EGD shows isolated
gastric varices. Cause, treatment?
• Gastric varices likely from splenic vein thrombosis from
pancreatitis, treatment is splenectomy.
• Patient POD#1 s/p roux-en-y bypass for obesity, now with
tachycardia, workup/diagnosis?
• Either PE or leak, will likely give symptoms suggesting one
or the other if PE -> CTA but treat with heparin
immeidately, MCC death after bypass

• If leak, can get water soluble study, need to go back to OR

early, fix leak, G-tube in remnant stomach.
• Patient with UGIB, EGD shows mass, bleeding controlled,
biopsy shows spindle cells. Diagnosis, management?
• GIST, wedge resection, no nodal dissection.
• Chemotherapy for GIST?
• Imatinib (Gleevec) for all malignant GISTS (>5mitosis/HPF,
>5cm)
• Treatment for MALT lymphoma?
• Treat H. pylori.
• Treatment for resectable intestinal type gastric CA in upper
1/3rd of stomach?
• Middle 1/3rd?
• Lower 1/3rd?
• Total gastrectomy
• Can consider distal gastrectomy if able to achieve 5cm
margin, no such thing as proximal gastrectomy.

• ALL diffuse type get total gastrectomy

Liver
• Most common anatomical variant of blood supply?
• Replaced right hepatic off SMA
• Location of a replaced left hepatic?
• Through the gastrohepatic ligament, off left gastric
• What divides the right and left lobe of the liver?
• Cantile’s line, between gall bladder fossa and IVC
• Coinaud segments of the left and right lobe?
• Anatomy of the hepatoduodenal ligament?
• Hepatic artery anteromedial
• Bile duct anterolateral
• Portal vein posterior
• Primary bile acids?
• Cholic and chenodeoxycholic acid
• Contents of bile?
• Bile acids, phospholipids, cholesterol, bilirubin
• Ratios that promote stone formation?
• Low bile acids, phospholipids
• High cholesterol
• Components of Childs Pugh score?
• Albumin, bilirubin, INR, encephalopathy and ascites
• Components of MELD?
• Bilrubin, INR, creatinine
• MELD cutoff for transplant?
• 15
• Patient with childs C cirrhosis and umbilical hernia which is
leaking ascites, treatment?
• Repair, risk of rupture and spontaneous bacterial
peritonitis.

• Don’t repair unless leaking or necrotic overlying skin.

• Bleeding esophageal varices management?
• Sengstaken blakemore tube
• EGD with banding
• Medical therapy with vasopressin, octreotide
• TIPS for refractory bleeding
• Main side effect of TIPS?
• Worsening of hepatic encephalopathy
• Patient with RUQ abdominal pain, CT shows, diagnosis
and management?
• Hydatid (Echinococcal) cyst.
• Diagnose by serology
• Treat with mebendazole/albendazole pre-op
• Resect and avoid rupture of cyst to prevent anaphylaxis
• PAIR (Percutaneous aspiration, injection with alcohol,
reaspiration) may be an option
• Patient with recent travel to mexico, now with RUQ pain,
CT/US shows large heterogeneous collection, diagnosis,
workup and management?
• Amoebic abscess, diagnose with enzyme immunoassay
for E. histolytica.
• First line treatment is flagyl, consider percutaneous
drainage for refractory abscess or superinfected with
bacteria
• Young woman on OCPs with large liver mass, diagnosis
and treatment?
• Hepatic adenoma
• Stop OCPs, if <4cm and asymptomatic can observe with
serial CTs
• If >4cm, symptomatic, persistent resect
• Diagnostic features and treatment of FNH?
• Central stellate scar
• Positive sulfur colloid scan (Kuppfer cells)

• Usually asymptomatic

• Only resect if unsure of the diagnosis

• Hemangiomas?
• Peripheral to central enhancement
• Do not biopsy
• Generally do not resect
• Milan criteria for HCC?
• One tumor <5
• 3 tumors <3
• No extra-hepatic manifestations
• No vascular invasion
Biliary system
• Blood supply to the common bile duct?
• 3 and 9 o’clock arteries off the right hepatic and
gastroduodenal arteries
• Effects of morphine and CCK on the sphincter of oddi?
• Morphine contracts
• CCK relaxes
• Describe the critical view of safety
• Two tubular structures entering the gall bladder with the
liver bed visible in the background.
• Patient undergoing lap chole, IOC shows a filling defect in
distal CBD, net step?
• Flush, give glucagon 1mg
• If that fails other options?
• Fogarty balloon sweeps, choledochoscope, basket, close
and perform ERCP if all else fails.
• Patient receiving lap chole, difficult dissection, IOC shows
clip traversing distal CBD, next steps?
• Convert to open, perform immediate hepaticojejunostomy
• Lap chole, notice sharp injury to CBD <50% circumference
treatment?
• Repair primarily over a T-tube
• Three causes of fluid collection s/p lap chole
• Bleeding/hematoma
• Bile leak
• Succus from bowel injury
• Patient s/p lap chole returns with RUQ pain, U/S shows
fluid collection, no ductal dilation, mildly elevated T and D
bili, IR drains bile, most likely diagnosis and treatment?
• Most likely cystic duct stump leak or duct of lushka
• HIDA/ERCP
• Stent
• Now, no fluid collection, intra-hepatic ductal dilation,
marked elevation in T and D bili, most likely diagnosis and
treatment?
• Major bile duct injury
• ERCP or PTC
• If noticed very early can consider early repair
• If noticed late, likely drainage, stenting and delayed repair
6-8 weeks later
• Indications for operating on gall bladder polyps?
• Stones present
• > 1 cm
• Sessile
• Malignant appearing
• Symptomatic gall bladder disease
• Charcot’s triad?
• Fever, jaundice, RUQ pain
• Reynolds’ pentad?
• Add mental status changes and shock
• Patient with cholangitis, next step?
• Antibiotics first, then biliary decompression
• Patient with bile duct obstruction from pancreatic CA, has
PTC placed, now with UGIB and blood in PTC tube,
diagnosis and treatment?
• Hemobilia
• Angioembolization
• Elderly patient with SBO, diagnosis and treatment?
• Images show gallstone in the small bowel and air in the
biliary tree.
• Diagnosis is gallstone ileus
• Treatment is laparotomy, proximal enterotomy, milk stone
back, run bowel to ensure no more stones, only deal with
fistula/cholecystectomy in rock solid stable patients
• Patient with obstructive jaundice, found to have
cholangiocarcinoma in lower 1/3rd of bile duct, no mets,
treatment?
• Whipple
• Now with tumor at junction of right and left hepatic duct,
treatment?
• Either resection with two hepatic jejunostomies if resultant
ducts are long enough, or if tumor goes up one side or the
other, ipsilateral hepatic lobectomy with heptico-
jejunostomy to the contralateral duct
• Patient s/p lap chole, find adenocarcinoma that is confined
to lamina propria, next step?
• Nothing, lap chole sufficient
• Tumor invades muscularis propria, next step?
• Take back to OR for wedge resection of gall bladder fossa,
segments IV b and V and lymphadenectomy of the
hepatoduodenal ligament
Pancreas
• Ventral pancreatic bud forms?
• Dorsal pancreatic bud forms?
• Ventral - Head and uncinate, contains main pancreatic
duct of wirsung
• Dorsal – tail and body, contains accessory duct of santorini
• Ducts usually fuse
• Newborn with down’s syndrome and partial obstruction in
the 2nd portion of the duodenum, diagnosis and treatment?
• Annular pancreas, Duodenoduodenostomy or
duodenojejunostomy, do not resect or divide the pancreas
• Patient with recurrent bouts of pancreatitis, diagnosis and
treatment?
• Pancreas divisum, major papilla is duct of wirsung draining
head and uncinate, minor papilla is duct of santorini
draining body and tail, treatment is sphincterotomy or open
sphincteroplasty if that fails
• Patient with abdominal pain, elevated lipase, sick,
diagnosis and treatment?
• Infected pancreatic necrosis, pancreatic necrosectomy
• Alcoholic with chronic abdominal pain and weight loss,
Diagnosis and treatment options?
• Chronic pancreatitis
• Initially pain control and pancreatic enzyme replacement,
celiac block, lateral pancreaticojejunostomy if duct
enlarged (Puestow), distal pancreatectomy if only tail
affected, whipple if only head affected
• Indications for intervening on pancreatic pseudocysts?
• Minimum of 6-8 weeks of symptoms
• Mature cyst wall
• Inability to rule out cancer (complex cysts, no history of
pancreatitis, continues to enlarge on CT)
• Generally size >5cm

• Treatment is cyst gastrostomy or cyst jejunostomy

• Patient with acute bout of pancreatitis recently with
pseudocyst, now with massive UGIB, differential diagnosis
and treatment?
• Splenic (or other) artery pseudoaneurysm, IR for
angioembolization
• Gastric varices from splenic vein thrombosis and
splenectomy
• Differential diagnosis of cystic lesions of the pancreas?
• Cystic lesion on imaging, high amylase, high CEA, next
step, definitive treatment?
• IPMN, get ERCP/MRCP, if main duct connection or
complex needs resection, if branch duct and no other
concerning signs of malignancy, can watch closely
• Middle aged woman with cystic pancreatic lesion, FNA
shows ovarian like stroma, diagnosis and treatment?
• Mucinous cystic neoplasm, resection
• Patient with cystic lesion of pancreas, small,
asymptomatic, FNA shows low amylase, low CEA,
diagnosis and management?
• Serous cystadenoma, can watch
• Patient with painless jaundice, weight loss, likely
diagnosis?
• Pancreatic CA
• Things that make you borderline/unresectable?
• Mets
• Greater than 180 degree encasement of celiac or SMA
• Anything more than limited involvement of SMV or portal
vein
• Para-aortic, celiac or SMA nodes
• Patient s/p whipple now with massive UGIB, diagnosis and
treatment?
• Blowout of GDA, IR for embolization
• Patient s/p distal pancreatectomy, now with large
abdominal fluid collection, diagnosis and management?
• Likely pancreatic fistula
• Tap, send for amylase
• Ductal drainage with ERCP/sphincterotomy/stent
• Non-operative management,
• Determine if high or low output
• Optimize nutrition
• Octreotide
• Surgery is last resort
• Patient with fasting hypoglycemia, palpitations,
diaphoresis, which resolve with OJ, diagnosis, workup and
treatment?
• Insulinoma, labs (fasting insulin and glucose ration >0.4,
check C peptide) imaging with CT, EUS (not octreotide
scan)
• Can enucleate if small (<2cm) and not right on main duct,
or resect
• Patient with multiple recalcitrant gastric and duodenal
ulcers, diagnosis, workup, and treatment?
• Gastrinoma
• Labs
• serum gastrin (usually >200, >1000 virtually diagnostic)
• basal acid output (>15mEq/hr),
• Secretin stimulation test (see increase in gastrin with
gastrinoma, normal patients have decrease),
• Imaging
• CT
• EUS
• octreotide scan
• Look for signs of MEN
• Can enucleate if small, resect if large, debulk if metastatic
• Patient with pancreatic mass, diabetes, gallstones, and
steatorrhea, diagnosis?
• Somatostatinoma
• Patient with diabetes and dermatitis?
• Glucagonoma
• Diarrhea, hypokalemia, achlorhydria?
• VIPoma, Verner-Morrison syndrome, WDHA syndrome
Spleen
• Vaccines needed after splenectomy?
• H. Flu
• Pneumococcus
• Meningococcus
• Best time to give vaccines?
• 2 weeks pre-op
• Give prior to discharge in unexpected splenectomy due to
concern for loss of follow up
• Young woman with petechiae, platelet count 10, diagnosis,
mechanism, and treatment algorithm?
• ITP from anti-platelet antibodies
• Steroids first line, IVIG second line, rituximab
• Splenectomy for disease refractory to medical therapy
• If necessary when do you give platelets with splenectomy?
• Once splenic artery is ligated (done first)
• Patient with low platelets, altered mental status, kidney
failure, fever, and purpura, diagnosis and treatment?
• TTP, plasmapheresis
• Patient with anemia from spectrin mutation, diagnosis and
treatment?
• Hereditary spherocytosis, splenectomy
• Patient with sepsis, bacteremia, diagnosis and
management?
• Splenic abscess, splenectomy (generally don’t drain,
unless this is after splenic artery embolization)
Small Bowel
• Main site of iron absorption?
• duodenum
• Site of B12 absorption?
• Terminal ileum
• Indications for operating in Crohn’s disease?
• Obstruction, perforation, cancer/dysplasia, failure of
medical therapy
• Patient with obstruction due to stricture in TI, treatment?
• Stricturoplasty
• Heinecke-Mikulicz
• Finney
• Jaboulay (bypass)
• If too long segmental resection
• What are your margins of resection in Crohn’s disease?
• Resect until free of gross disease
• Patient with carcinoid of small bowel, treatment?
• Resection and lymphadenectomy
• Options for metastatic carcinoid?
• Debulking, octreotide
• Patient comes in with SBO, diagnosis and management?
• Intussusception, OR for resection
Colon and Rectum
• Indications for operating in ulcerative colitis?
• Perforation, toxic megacolon, hemorrhage despite
transfusion, dysplasia/cancer, failed medical therapy
• Patient with toxic megacolon, treatment?
• Total abdominal colectomy with end ileostomy
• Patient with dysplasia found on colonoscopy, treatment?
• Total proctocolectomy with IPAA
• Surveillance of patient with UC under control medically?
• Usually start after 8 years of disease with colonoscopy
every 1-2 years
• Which manifestations do not improve with colectomy?
• Primary sclerosing cholangitis and ankylosing spndylitis
• Elderly patient with N/V, distension, diagnosis and
management options?
• Sigmoid volvulus, if stable/no peritonitis can attempt
endoscopic decompression with resection same
hospitalization, if sick/peritonitis go right to OR
• Same patient
• Cecal volvulus, OR
• Patient s/p total knee replacement now with N/V/
distension, diagnosis and management?
• Ogilvie’s syndrome
• Medical management, correct electrolytes, NPO, NGT, IVF
• Neostigmine
• Colonoscopy
• Surgery reserved for perforation
• Major side effect of neostigmine?
• Bradycardia
• Hinchey classification?
• 50 yo patient with second bout of acute diverticulitis, had
large pelvic abscess that required drainage, now well in
your office 6 weeks later, what do you need prior to OR?
• Colonoscopy
• Patient with rectal mass found on colonoscopy at 10cm,
path shows adenoCA, workup?
• Staging with CT chest, A/P, local staging with EUS/MRI
• Indications for trans-anal excision of rectal cancer?
• T1 lesion, does not penetrate muscularis
• <4cm
• <1/3rd circumference
• Tumor penetrates through muscularis or has nodes?
• T3, or any N, Neo-adjuvant chemorads, then resection
• Distal margin needed?
• 2cm
• Gene mutation in FAP?
• APC tumor suppressor gene
• Inheritance?
• Autosomal dominant
• Surgical options?
• Total proctocolectomy, rectal mucosectomy, with IPAA
• Surveillance after surgery?
• EGDs to look for duodenal adenomas
• Surveillance of pouch to look for tumors/polyps of residual
rectal area
• Patient s/p total proctocolectomy with IPAA for FAP now
with rectal pain and bloody diarrhea, diagnosis and
treatment?
• Pouchitis, diagnose with pouchoscopy, treat with
antibiotics (levo/flag)
• Patient with total proctocolectomy and IPAA for FAP now
with abdominal pain, diagnosis and treatment?
• Desmoid, resect if localized, other options include NSAIDs
(sulindac), anti-estrogens (tamoxifen), XRT
• Mechanism of lynch syndrome?
• HNPCC, micro-satellite instability, defects in DNA
mismatch repair genes (hMSH)
• Amsterdam criteria for diagnosis?
• 3 – relatives (1 first degree)
• 2 – generations
• 1 – relative with CA prior to age 50
• Patient s/p appendectomy with carcinoid on path,
management?
• If >2cm, involving base needs R hemicolectomy, if <2cm
and not involving base appendectomy is sufficient
Anorectal
• Patient with exquisitely painful lump in peri-anal area, pain
started 8 hours ago, diagnosis and treatment?
• Incise and remove clot, if >48-72 hours of pain just
manage symptoms, usually resolve
• Contraindications to hemorrhoid banding?
• Any external hemorrhoids, too painful
• Patient s/p hemorrhoid banding in office, now in ED 2 days
later, urinary retention and fever, next step?
• CT scan, worry about pelvic sepsis
• Patient with intense pain with defecation, can do digital
exam but see skin tag, diagnosis and treatment?
• Anal fissure, initially conservative management with stool
softeners, sitz baths, lidocaine jelly, nitro cream
• If medical management fails, lateral internal
sphincterotomy
• Patient with peri-anal lesion, biopsy shows squamous cell
CA, treatment?
• Nigro protocol, 5-FU, mitomycin and XRT, every year
• Patient with fistula in ano, treatment?
• Low (internal opening below dentate line) drain abscess
and unroof fistula
• High (above dentate line) will get incontinence with
unroofing, drain abscess and place seton, long term
options include rectal advancement flaps, plugs etc
• Patient with rectal prolapse, surgical options?
• If young and healthy, trans-abdominal procedure, resection
rectopexy
• If old and frail, perineal procedure, delorme (mucosal
resection/plication) or altemeier (full thickness resection)
Hernias
Pedi
Skin and Soft Tissue
Urology
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Neurosurgery
Orthopedics