- •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
|
Chapter 52 / Liver 349 |
What is the mortality in |
Increase in mortality by 1% per 1 point |
cirrhotic patients for |
in the MELD score until 20, then 2% for |
nonemergent nontransplant |
each MELD point |
surgery? |
|
What is the mortality in |
14% increase in mortality per 1 point of |
cirrhotic patients for |
the MELD score |
emergent nontransplant |
|
surgery? |
|
TUMORS OF THE LIVER |
|
|
|
What is the most common |
Metastatic disease outnumbers primary |
liver cancer? |
tumors 20:1; primary site is usually the |
|
GI tract |
What is the most common |
Hepatocellular carcinoma (hepatoma) |
primary malignant liver |
|
tumor? |
|
What is the most common primary benign liver tumor?
What lab tests comprise the workup for liver metastasis?
What are the associated imaging studies?
What is a right hepatic lobectomy?
What is a left hepatic lobectomy?
What is a right trisegmentectomy?
What are the three common types of primary benign liver tumors?
Hemangioma
LFTs (AST and alkaline phosphatase are most useful), CEA for suspected primary colon cancer
CT scan, ultrasound, A-gram
Removal of the right lobe of the liver (i.e., all tissue to the right of Cantle’s line is removed)
Removal of the left lobe of the liver (i.e., removal of all the liver tissue to the left of Cantle’s line)
Removal of all the liver tissue to the right of the falciform ligament
1.Hemangioma
2.Hepatocellular adenoma
3.Focal nodular hyperplasia
350 Section II / General Surgery |
|
What are the four common |
1. Hepatocellular carcinoma (hepatoma) |
types of primary malignant |
2. Cholangiocarcinoma (when |
liver tumors? |
intrahepatic) |
|
3. Angiosarcoma (associated with chemical |
|
exposure) |
|
4. Hepatoblastoma (most common in |
|
infants and children) |
What chemical exposures |
Vinyl chloride, arsenic, thorotrast |
are risk factors for |
contrast |
angiosarcoma? |
|
What is a “hepatoma”? |
Hepatocellular carcinoma |
What are the other benign |
Benign liver cyst, bile duct hamartomas, |
liver masses? |
bile duct adenoma |
What is a liver “hamartoma”? |
White hard nodule made up of normal |
|
liver cells |
HEPATOCELLULAR ADENOMA |
|
|
|
What is it? |
Benign liver tumor |
Describe the histology. |
Normal hepatocytes without bile ducts |
What are the associated risk |
Women, birth control pills (Think: |
factors? |
ABC Adenoma Birth Control), |
|
anabolic steroids, glycogen storage |
|
disease |
What is the female:male ratio?
What is the average age of occurrence?
What are the signs/ symptoms?
What are the possible complications?
How is the diagnosis made?
9:1
30–35 years of age
RUQ pain/mass, RUQ fullness, bleeding (rare)
Rupture with bleeding (33%), necrosis, pain, risk of hepatocellular carcinoma
CT scan, U/S, /– biopsy (rule out hemangioma with RBC-tagged scan!)
|
Chapter 52 / Liver 351 |
What is the treatment: |
|
Small? |
Stop birth control pills—it may |
|
regress; if not, surgical resection |
|
is necessary |
Large ( 5 cm), bleeding, |
Surgical resection |
painful, or ruptured? |
|
FOCAL NODULAR HYPERPLASIA (FNH)
What is it?
Describe the histology.
What is the average age of occurrence?
What are the associated risk factors?
Are the tumors associated with birth control pills?
How is the diagnosis made?
What is the classic CT scan finding?
What are the possible complications?
Is there a cancer risk with FNH?
What is the treatment?
Benign liver tumor
Normal hepatocytes and bile ducts
(adenoma has no bile ducts)
40 years
Female gender
Yes, but not as clearly associated as with adenoma
Nuclear technetium-99 study, U/S, CT scan, A-gram, biopsy
Liver mass with “central scar” (Think: focal central)
Pain (no risk of cancer, very rarely hemorrhage)
No (there is a cancer risk with adenoma)
Resection or embolization if patient is symptomatic; otherwise, follow if diagnosis is confirmed; stop birth control pills
Why does embolization work FNH tumors are usually fed by one with FNH? major artery
352 Section II / General Surgery
HEPATIC HEMANGIOMA
What is it? |
Benign vascular tumor of the liver |
What is its claim to fame? |
Most common primary benign liver |
|
tumor (up to 7% of population) |
What are the signs/symptoms? |
RUQ pain/mass, bruits |
What are the possible |
Pain, congestive heart failure, coagulopathy, |
complications? |
obstructive jaundice, gastric outlet |
|
obstruction, Kasabach-Merritt syndrome, |
|
hemorrhage (rare) |
Define Kasabach-Merritt |
Hemangioma and thrombocytopenia and |
syndrome? |
fibrinogenopenia |
How is the diagnosis made? |
CT scan with IV contrast, tagged red |
|
blood scan, MRI, ultrasound |
Should biopsy be performed? |
No (risk of hemorrhage with biopsy) |
What is the treatment? |
Observation ( 90%) |
What are the indications for |
Symptoms, hemorrhage, cannot make a |
resection? |
diagnosis |
HEPATOCELLULAR CARCINOMA |
|
|
|
What is it? |
Most common primary malignancy of the |
|
liver |
By what name is it also |
Hepatoma |
known? |
|
What is its incidence? |
Accounts for 80% of all primary |
|
malignant liver tumors |
What are the geographic |
Africa and Asia |
high-risk areas? |
|
What are the associated risk |
Hepatitis B virus, cirrhosis, aflatoxin |
factors? |
(fungi toxin of Aspergillus flavus); Other |
|
risk factors: -1-antitrypsin deficiency, |
|
hemochromatosis, liver fluke (Clonorchis |
|
sinensis), anabolic steroids, polyvinyl |
|
chloride, glycogen storage disease (type I) |
What percentage of patients with cirrhosis will develop hepatocellular carcinoma?
What are the signs/ symptoms?
Chapter 52 / Liver 353
5%
Dull RUQ pain, hepatomegaly (classic presentation: painful hepatomegaly), abdominal mass, weight loss, paraneoplastic syndromes, signs of portal hypertension, ascites, jaundice, fever, anemia, splenomegaly
What tests should be ordered?
What is the tumor marker?
What is the most common way to get a tissue diagnosis?
What is the most common site of metastasis?
What is the treatment of hepatocellular carcinoma?
What are the treatment options if the patient is not a surgical candidate?
What are the indications for liver transplantation?
What is the prognosis under the following conditions:
Unresectable?
Resectable?
Which subtype has the best prognosis?
Ultrasound, CT scan, angiography, tumor marker elevation
Elevated -fetoprotein
Needle biopsy with CT scan, ultrasound, or laparoscopic guidance
Lungs
Surgical resection, if possible (e.g., lobectomy); liver transplant
Percutaneous ethanol tumor injection, cryotherapy, and intra-arterial chemotherapy
Cirrhosis and NO resection candidacy as well as no distant or lymph node metastases and no vascular invasion; the tumor must be single, 5-cm tumor or have three nodules, with none 3 cm
Almost none survive a year
35% are alive at 5 years
Fibrolamellar hepatoma (young adults)