- •Dedication
- •Editors and Contributors
- •Foreword
- •Preface
- •Contents
- •PREPARING FOR THE SURGERY CLERKSHIP
- •SURGICAL NOTES
- •COMMON ABBREVIATIONS YOU SHOULD KNOW
- •RETRACTORS (YOU WILL GET TO KNOW THEM WELL!)
- •SUTURE MATERIALS
- •WOUND CLOSURE
- •KNOTS AND EARS
- •INSTRUMENT TIE
- •TWO-HAND TIE
- •COMMON PROCEDURES
- •NASOGASTRIC TUBE (NGT) PROCEDURES
- •CHEST TUBES
- •NASOGASTRIC TUBES (NGT)
- •FOLEY CATHETER
- •CENTRAL LINES
- •MISCELLANEOUS
- •THIRD SPACING
- •COMMON IV REPLACEMENT FLUIDS (ALL VALUES ARE PER LITER)
- •CALCULATION OF MAINTENANCE FLUIDS
- •ELECTROLYTE IMBALANCES
- •ANTIBIOTICS
- •STEROIDS
- •HEPARIN
- •WARFARIN (COUMADIN®)
- •MISCELLANEOUS AGENTS
- •NARCOTICS
- •MISCELLANEOUS
- •ATELECTASIS
- •POSTOPERATIVE RESPIRATORY FAILURE
- •PULMONARY EMBOLISM
- •ASPIRATION PNEUMONIA
- •GASTROINTESTINAL COMPLICATIONS
- •ENDOCRINE COMPLICATIONS
- •CARDIOVASCULAR COMPLICATIONS
- •MISCELLANEOUS
- •HYPOVOLEMIC SHOCK
- •SEPTIC SHOCK
- •CARDIOGENIC SHOCK
- •NEUROGENIC SHOCK
- •MISCELLANEOUS
- •URINARY TRACT INFECTION (UTI)
- •CENTRAL LINE INFECTIONS
- •WOUND INFECTION (SURGICAL SITE INFECTION)
- •NECROTIZING FASCIITIS
- •CLOSTRIDIAL MYOSITIS
- •SUPPURATIVE HIDRADENITIS
- •PSEUDOMEMBRANOUS COLITIS
- •PROPHYLACTIC ANTIBIOTICS
- •PAROTITIS
- •MISCELLANEOUS
- •CHEST
- •ABDOMEN
- •MALIGNANT HYPERTHERMIA
- •MISCELLANEOUS
- •OVERVIEW
- •CHOLECYSTOKININ (CCK)
- •SECRETIN
- •GASTRIN
- •SOMATOSTATIN
- •MISCELLANEOUS
- •GROIN HERNIAS
- •HERNIA REVIEW QUESTIONS
- •ESOPHAGEAL HIATAL HERNIAS
- •PRIMARY SURVEY
- •SECONDARY SURVEY
- •TRAUMA STUDIES
- •PENETRATING NECK INJURIES
- •MISCELLANEOUS TRAUMA FACTS
- •PEPTIC ULCER DISEASE (PUD)
- •DUODENAL ULCERS
- •GASTRIC ULCERS
- •PERFORATED PEPTIC ULCER
- •TYPES OF SURGERIES
- •STRESS GASTRITIS
- •MALLORY-WEISS SYNDROME
- •ESOPHAGEAL VARICEAL BLEEDING
- •BOERHAAVE’S SYNDROME
- •ANATOMY
- •GASTRIC PHYSIOLOGY
- •GASTROESOPHAGEAL REFLUX DISEASE (GERD)
- •GASTRIC CANCER
- •GIST
- •MALTOMA
- •GASTRIC VOLVULUS
- •SMALL BOWEL
- •APPENDICITIS
- •CLASSIC INTRAOPERATIVE QUESTIONS
- •APPENDICEAL TUMORS
- •SPECIFIC TYPES OF FISTULAS
- •ANATOMY
- •COLORECTAL CARCINOMA
- •COLONIC AND RECTAL POLYPS
- •POLYPOSIS SYNDROMES
- •DIVERTICULAR DISEASE OF THE COLON
- •ANATOMY
- •ANAL CANCER
- •ANATOMY
- •TUMORS OF THE LIVER
- •ABSCESSES OF THE LIVER
- •HEMOBILIA
- •ANATOMY
- •PHYSIOLOGY
- •PATHOPHYSIOLOGY
- •DIAGNOSTIC STUDIES
- •BILIARY SURGERY
- •OBSTRUCTIVE JAUNDICE
- •CHOLELITHIASIS
- •ACUTE CHOLECYSTITIS
- •ACUTE ACALCULOUS CHOLECYSTITIS
- •CHOLANGITIS
- •SCLEROSING CHOLANGITIS
- •GALLSTONE ILEUS
- •CARCINOMA OF THE GALLBLADDER
- •CHOLANGIOCARCINOMA
- •MISCELLANEOUS CONDITIONS
- •PANCREATITIS
- •PANCREATIC ABSCESS
- •PANCREATIC NECROSIS
- •PANCREATIC PSEUDOCYST
- •PANCREATIC CARCINOMA
- •MISCELLANEOUS
- •ANATOMY OF THE BREAST AND AXILLA
- •BREAST CANCER
- •DCIS
- •LCIS
- •MISCELLANEOUS
- •MALE BREAST CANCER
- •BENIGN BREAST DISEASE
- •CYSTOSARCOMA PHYLLODES
- •FIBROADENOMA
- •FIBROCYSTIC DISEASE
- •MASTITIS
- •BREAST ABSCESS
- •MALE GYNECOMASTIA
- •ADRENAL GLAND
- •ADDISON’S DISEASE
- •INSULINOMA
- •GLUCAGONOMA
- •SOMATOSTATINOMA
- •ZOLLINGER-ELLISON SYNDROME (ZES)
- •MULTIPLE ENDOCRINE NEOPLASIA
- •THYROID DISEASE
- •ANATOMY
- •PHYSIOLOGY
- •HYPERPARATHYROIDISM (HPTH)
- •PARATHYROID CARCINOMA
- •SOFT TISSUE SARCOMAS
- •LYMPHOMA
- •SQUAMOUS CELL CARCINOMA
- •BASAL CELL CARCINOMA
- •MISCELLANEOUS SKIN LESIONS
- •STAGING
- •INTENSIVE CARE UNIT (ICU) BASICS
- •INTENSIVE CARE UNIT FORMULAS AND TERMS YOU SHOULD KNOW
- •SICU DRUGS
- •INTENSIVE CARE PHYSIOLOGY
- •HEMODYNAMIC MONITORING
- •MECHANICAL VENTILATION
- •PERIPHERAL VASCULAR DISEASE
- •LOWER EXTREMITY AMPUTATIONS
- •ACUTE ARTERIAL OCCLUSION
- •ABDOMINAL AORTIC ANEURYSMS
- •MESENTERIC ISCHEMIA
- •MEDIAN ARCUATE LIGAMENT SYNDROME
- •CAROTID VASCULAR DISEASE
- •CLASSIC CEA INTRAOP QUESTIONS
- •SUBCLAVIAN STEAL SYNDROME
- •RENAL ARTERY STENOSIS
- •SPLENIC ARTERY ANEURYSM
- •POPLITEAL ARTERY ANEURYSM
- •MISCELLANEOUS
- •PEDIATRIC IV FLUIDS AND NUTRITION
- •PEDIATRIC BLOOD VOLUMES
- •FETAL CIRCULATION
- •ECMO
- •NECK
- •ASPIRATED FOREIGN BODY (FB)
- •CHEST
- •PULMONARY SEQUESTRATION
- •ABDOMEN
- •INGUINAL HERNIA
- •UMBILICAL HERNIA
- •GERD
- •CONGENITAL PYLORIC STENOSIS
- •DUODENAL ATRESIA
- •MECONIUM ILEUS
- •MECONIUM PERITONITIS
- •MECONIUM PLUG SYNDROME
- •ANORECTAL MALFORMATIONS
- •HIRSCHSPRUNG’S DISEASE
- •MALROTATION AND MIDGUT VOLVULUS
- •OMPHALOCELE
- •GASTROSCHISIS
- •POWER REVIEW OF OMPHALOCELE AND GASTROSCHISIS
- •APPENDICITIS
- •INTUSSUSCEPTION
- •MECKEL’S DIVERTICULUM
- •NECROTIZING ENTEROCOLITIS
- •BILIARY TRACT
- •TUMORS
- •PEDIATRIC TRAUMA
- •OTHER PEDIATRIC SURGERY QUESTIONS
- •POWER REVIEW
- •WOUND HEALING
- •SKIN GRAFTS
- •FLAPS
- •SENSORY SUPPLY TO THE HAND
- •CARPAL TUNNEL SYNDROME
- •ANATOMY
- •MISCELLANEOUS
- •NOSE AND PARANASAL SINUSES
- •ORAL CAVITY AND PHARYNX
- •FACIAL FRACTURES
- •ENT WARD QUESTIONS
- •RAPID-FIRE REVIEW OF MOST COMMON CAUSES OF ENT INFECTIONS
- •THORACIC OUTLET SYNDROME (TOS)
- •CHEST WALL TUMORS
- •DISEASES OF THE PLEURA
- •DISEASES OF THE LUNGS
- •DISEASES OF THE MEDIASTINUM
- •DISEASES OF THE ESOPHAGUS
- •ACQUIRED HEART DISEASE
- •CONGENITAL HEART DISEASE
- •CARDIAC TUMORS
- •DISEASES OF THE GREAT VESSELS
- •MISCELLANEOUS
- •BASIC IMMUNOLOGY
- •CELLS
- •IMMUNOSUPPRESSION
- •OVERVIEW OF IMMUNOSUPPRESSION MECHANISMS
- •MATCHING OF DONOR AND RECIPIENT
- •REJECTION
- •ORGAN PRESERVATION
- •KIDNEY TRANSPLANT
- •LIVER TRANSPLANT
- •PANCREAS TRANSPLANT
- •HEART TRANSPLANT
- •INTESTINAL TRANSPLANTATION
- •LUNG TRANSPLANT
- •TRANSPLANT COMPLICATIONS
- •ORTHOPAEDIC TERMS
- •TRAUMA GENERAL PRINCIPLES
- •FRACTURES
- •ORTHOPAEDIC TRAUMA
- •DISLOCATIONS
- •THE KNEE
- •ACHILLES TENDON RUPTURE
- •ROTATOR CUFF
- •MISCELLANEOUS
- •ORTHOPAEDIC INFECTIONS
- •ORTHOPAEDIC TUMORS
- •ARTHRITIS
- •PEDIATRIC ORTHOPAEDICS
- •HEAD TRAUMA
- •SPINAL CORD TRAUMA
- •TUMORS
- •VASCULAR NEUROSURGERY
- •SPINE
- •PEDIATRIC NEUROSURGERY
- •SCROTAL ANATOMY
- •UROLOGIC DIFFERENTIAL DIAGNOSIS
- •RENAL CELL CARCINOMA (RCC)
- •BLADDER CANCER
- •PROSTATE CANCER
- •BENIGN PROSTATIC HYPERPLASIA
- •TESTICULAR CANCER
- •TESTICULAR TORSION
- •EPIDIDYMITIS
- •PRIAPISM
- •ERECTILE DYSFUNCTION
- •CALCULUS DISEASE
- •INCONTINENCE
- •URINARY TRACT INFECTION (UTI)
- •MISCELLANEOUS UROLOGY QUESTIONS
- •Rapid Fire Power Review
- •TOP 100 CLINICAL SURGICAL MICROVIGNETTES
- •Figure Credits
- •Index
682 Section III / Subspecialty Surgery
What is the differential diagnosis of increased creatinine?
What are the signs/ symptoms?
What is the workup for the following tests:
U/S with Doppler?
Radionuclide scan?
Biopsy?
What is the time course for return of normal renal function after transplant?
LIVER TRANSPLANT
(Remember: “-TION”) obstrucTION, dehydraTION, infecTION, intoxicaTION (CSA); plus lymphocele, ATN
Fever, malaise, HTN, ipsilateral leg edema, pain at transplant site, oliguria
Look for fluid collection around the kidney, hydronephrosis, flow in vessels
Look at flow and function
Distinguish between rejection and cyclosporine toxicity
LRD—3 to 5 days
Deceased donor—7 to 15 days
Who performed the first |
Thomas Starzl (1963) |
|
liver transplant? |
|
|
What are the indications? |
Liver failure from: |
|
|
1. |
Cirrhosis (leading indication in |
|
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adults) |
|
2. |
Budd-Chiari |
|
3. |
Biliary atresia (leading indication |
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in children) |
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4. |
Neonatal hepatitis |
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5. |
Chronic active hepatitis |
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6. |
Fulminant hepatitis with drug |
|
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toxicity—acetaminophen |
|
7. |
Sclerosing cholangitis |
|
8. |
Caroli’s disease |
|
9. |
Subacute hepatic necrosis |
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10. |
Congenital hepatic fibrosis |
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11. |
Inborn errors of metabolism |
|
12. |
Fibrolamellar hepatocellular |
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carcinoma |
What is the MELD score?
Chapter 73 / Transplant Surgery 683
“Model for End Stage Liver Disease” is the formula currently used to assign points for prioritizing position on the waiting list for deceased donor liver transplant; based on INR, bilirubin, and creatinine with extra points given for the presence of liver cancer
What is the test for |
ABO typing |
compatibility? |
|
What is the placement? |
Orthotopic |
What are the options for |
1. Donor common bile to recipient |
biliary drainage? |
common bile duct end to end |
|
2. Roux-en-Y choledochojejunostomy |
What is the “piggyback |
Recipient vena cava is left in place; the |
technique”? |
donor infrahepatic IVC is oversewn; the |
|
donor superior IVC is anastomosed onto |
|
a cuff made from the recipient hepatic |
|
veins (allows for greater hemodynamic |
|
stability of the recipient during OLT) |
How does Living Donor |
Adult donates a left lateral segment to a |
Liver Transplantation |
child or an adult donates a right lobe to |
(LDLT) work? |
another adult |
What is a split liver |
Deceased donor liver is harvested |
transplant? |
and divided into two “halves” for two |
|
recipients |
What is chronic liver |
“Vanishing bile duct syndrome” |
rejection called? |
|
REJECTION |
|
|
|
What are the red flags |
Decreased bile drainage, increased |
indicating rejection? |
serum bilirubin, increased LFTs |
What is the site of rejection? |
Rejection involves the biliary epithelium |
|
first, and later, the vascular endothelium |
684 Section III / Subspecialty Surgery
What is the workup with the following tests:
U/S with Doppler?
Look at flow in portal vein, hepatic artery; rule out thrombosis, leaky anastomosis, infection (abscess)
Cholangiogram? |
Look at bile ducts (easy to do; patients |
|
usually have a T-tube if they have |
|
primary biliary anastomosis) |
Biopsy? |
Especially important 3 to 6 weeks |
|
postoperatively, when CMV is of |
|
greatest concern |
Does hepatorenal syndrome |
Yes |
renal function improve after |
|
liver transplant? |
|
SURVIVAL STATISTICS |
|
|
|
What is the 1-year survival |
80% to 85% |
rate? |
|
What percentage of patients |
20% |
requires retransplant? |
|
Why? |
Usually primary graft dysfunction, |
|
rejection, infection, vascular thrombosis, |
|
or recurrence of primary disease |
PANCREAS TRANSPLANT |
|
|
|
Who performed the first |
Richard C. Lillehei and William D. Kelly |
pancreas transplant? |
(1966) |
What are the indications? |
Type I (juvenile) diabetes mellitus |
|
associated with severe complications |
|
(renal failure, blindness, neuropathy) or |
|
very poor glucose control |
What are the tests for compatibility?
ABO, DR matching (class II)
What is the placement? Heterotopic, in iliac fossa or paratopic
|
Chapter 73 / Transplant Surgery 685 |
|
Where is anastomosis of the |
To the bladder |
|
exocrine duct in heterotopic |
|
|
placement? |
|
|
|
|
h |
|
|
r |
|
|
f |
|
|
' |
|
|
0 |
|
|
2 |
|
Portal vein |
|
|
Iliac vein |
|
|
Graft |
|
|
duodenum |
|
|
Iliac artery |
Bladder |
Why? |
Measures the amount of amylase in |
|
|
urine, gives an indication of pancreatic |
|
function (i.e., high urine amylase indicates good pancreatic function)
What is the associated electrolyte complication?
Where is anastomosis of the exocrine duct in paratopic placement?
Why?
What is the advantage of paratopic placement?
What are the red flags indicating rejection?
Why should the kidney and pancreas be transplanted together?
Why is hyperglycemia not a good indicator for rejection surveillance?
Loss of bicarbonate
To the jejunum
It is close by and physiologic
Endocrine function drains to the portal vein directly to the liver, and pancreatic contents stay within the GI tract (no need to replace bicarbonate)
Hyperamylasemia, hyperglycemia, hypoamylasuria, graft tenderness
Kidney function is a better indicator of rejection; also better survival of graft is associated with kidney-pancreas transplant than pancreas alone
Hyperglycemia appears relatively late with pancreatic rejection