- •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 54 / Biliary Tract 377 |
What are the signs and |
Same as those for obstructive jaundice: |
symptoms of sclerosing |
Jaundice |
cholangitis? |
Itching (pruritus) |
|
Dark urine |
|
Clay-colored stools |
|
Loss of energy |
|
Weight loss |
|
(Many patients are asymptomatic) |
What are the complications? |
Cirrhosis |
|
Cholangiocarcinoma (10%) |
|
Cholangitis |
|
Obstructive jaundice |
How is it diagnosed? |
Elevated alkaline phosphatase, and PTC |
|
or ERCP revealing “beads on a string” |
|
appearance on contrast study |
What are the management |
Hepatoenteric anastomosis (if primarily |
options? |
extrahepatic ducts are involved) |
|
and resection of extrahepatic |
|
bile ducts because of the risk of |
|
cholangiocarcinoma |
|
Transplant (if primarily intrahepatic |
|
disease or cirrhosis) |
|
Endoscopic balloon dilations |
What percentage of patients |
5% |
with IBD develops sclerosing |
|
cholangitis? |
|
GALLSTONE ILEUS |
|
|
|
What is it? |
Small bowel obstruction from a large |
|
gallstone ( 2.5 cm) that has eroded |
|
through the gallbladder and into the |
|
duodenum/small bowel |
What is the classic site of obstruction?
Ileocecal valve (but may cause obstruction in the duodenum, sigmoid colon)
378 Section II / General Surgery
What are the classic findings of gallstone ileus?
Air in the hepatic bile ducts
SBO with air fluid levels
Gallstone in ileocecal valve
h rf
‘ 0 7
What is the population at risk?
What are the signs/ symptoms?
Gallstone ileus causes what percentage of cases of SBO?
What are the diagnostic tests of choice?
Gallstone ileus is most commonly seen in women older than 70 years
Symptoms of SBO: distention, vomiting, hypovolemia, RUQ pain
1%
Abdominal x-ray: occasionally reveals radiopaque gallstone in the bowel;
40% of patients show air in the biliary tract, small bowel distention, and air fluid levels secondary to ileus
UGI: used if diagnosis is in question; will show cholecystenteric fistula and the obstruction
Abdominal CT: reveals air in biliary tract, SBO /– gallstone in intestine
What is the management? Surgery: enterotomy with removal of the stone interval cholecystectomy (intervaldelayed)
CARCINOMA OF THE GALLBLADDER
What is it? |
Malignant neoplasm arising in the |
|
gallbladder, vast majority are |
|
adenocarcinoma (90%) |
|
Chapter 54 / Biliary Tract 379 |
What are the risk factors? |
Gallstones, porcelain gallbladder, |
|
cholecystenteric fistula |
What is the female:male ratio? |
4:1 |
What is the most common |
60% in fundus |
site of gallbladder cancer in |
|
the gallbladder? |
|
What is a porcelain |
Calcified gallbladder |
gallbladder? |
|
What percentage of patients |
50% (20%–60%) |
with a porcelain gallbladder |
|
will have gallbladder cancer? |
|
What is the incidence? |
1% of all gallbladder specimens |
What are the symptoms? |
Biliary colic, weight loss, anorexia; many |
|
patients are asymptomatic until late; may |
|
present as acute cholecystitis |
What are the signs? |
Jaundice (from invasion of the common duct |
|
or compression by involved pericholedochal |
|
lymph nodes), RUQ mass, palpable |
|
gallbladder (advanced disease) |
What are the diagnostic tests of choice?
What is the route of spread?
What is the management under the following conditions?
Confined to mucosa
Confined to muscularis/ serosa
Ultrasound, abdominal CT, ERCP
Contiguous spread to the liver is most common
Cholecystectomy
Radical cholecystectomy: cholecystectomy and wedge resection of overlying liver, and lymph node dissection chemotherapy/XRT
What is the main complication of a lap chole for gallbladder cancer?
Trocar site tumor implants (Note: if known preoperatively, perform open cholecystectomy)
380 Section II / General Surgery
What is the prognosis for gallbladder cancer?
CHOLANGIOCARCINOMA
Dismal overall: 5% 5-year survival as most are unresectable at diagnosis
T1 with cholecystectomy: 95% 5-year survival
What is it?
What is the histology?
Average age at diagnosis?
What are the signs and symptoms?
What is the most common location?
What are the risk factors?
What is a Klatskin tumor?
Malignancy of the extrahepatic or intrahepatic ducts—primary bile duct cancer
Almost all are adenocarcinomas
65 years, equally affects male/female
Those of biliary obstruction: jaundice, pruritus, dark urine, clay-colored stools, cholangitis
Proximal bile duct
Choledochal cysts Ulcerative colitis
Thorotrast contrast dye (used in 1950s) Sclerosing cholangitis
Liver flukes (clonorchiasis)
Toxin exposures (e.g., Agent Orange)
Tumor that involves the junction of the right and left hepatic ducts